2017-325-E Aging - Shu Hwa Fan for wellness instructor

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DocuSign Envelope ID:80CDDOE6-7F74-4289-9C39-8D8E11AOD8B6 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 03/21/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Mass Merchandising Underwriting K&K Insurance Group,Inc. PHONE 1-800-506-4856 FAX 1-260 459-5590 1712 Magnavox Way 1I MAILo,Ext): (Ale,No): Fort Wayne IN 46804 ADDRESS: info @fitnessinsurance-kk.com PRODUCER CUSTOMER ID: • INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: Nationwide Mutual Insurance Company 23787 Shu-Hwa Fan INSURER B: 120 Virginia Dr INSURER C: CHAPEL HILL,NC 27514 A Member of the Sports,Leisure&Entertainment RPG INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: W00999323 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MWDD/YYYY) (MMIDD/YYYY) A X COMMERCIAL GENERAL LIABILITY 6BRPG0000006028600 03/21/2017 03/21/2018 EACH OCCURRENCE $1,000,000 CLAIMS- X OCCUR 11:15 AM EDT 12:01 AM DAMAGE TO RENTED MADE _ PREMISES(Ea Occurrence) $300+00 MED EXP(Any one person) $5,000 PERSONAL&ADVINJURY $1,000,000 GENERAL AGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS–COMP/OP AGG $1,000,000 POLICY JET LOC PROFESSIONAL LIABILITY $1,000,000 OTHER: LEGAL LIAB TO PARTICIPANTS $1,000,000 AUTOMOBILE COMBINED SINGLE LIMIT UTOMOBILE LIABILITY (Ea accident) ANY AUTO BODILY INJURY(Per person) OWNED AUTOS SCHEDULED BODILY INJURY(Per accident) ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) NOT PROVIDED WHILE IN HAWAII UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB H CLAIMS-MADE AGGREGATE DED RETENTION WORKERS COMPENSATION AND N/A PER OTHER EMPLOYERS'LIABILITY _STATUTE— ANY PROPRIETOR/PARTNER/ YIN E.L.EACH ACCIDENT EXECUTIVE OFFICER/MEMBER EXCLUDED?(Mandatory in NH) E.L DISEASE–EA EMPLOYEE If yes,describe under DESCRIPTION E.L.DISEASE–POLICY LIMIT OF OPERATIONS below MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL EXCESS MEDICAL DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Molestation,Harassment or Sexual Conduct Defense Cost Reimbursement—Limit$100,000 Certified Instructor of:Exercise,Tai Chi CERTIFICATE HOLDER CANCELLATION Evidence of Coverage SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 4y - Coverage is only extended to U.S.events and activities. **NOTICE TO TEXAS INSUREDS:The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD