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DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9
<br /> ACOR°1 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
<br /> 07/24/2017
<br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
<br /> CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
<br /> THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
<br /> REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
<br /> IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
<br /> If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
<br /> this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
<br /> PRODUCER CONTACT NAME: Mass Merchandising
<br /> K&K Insurance Group, Inc. PHONE FAX 1-260-459-5940
<br /> (A/C, Ext): / , o):
<br /> 1712 Magnavox Way E-MAIL
<br /> Fort Wayne IN 46804 ADDRESS: info@martialartsinsurance-kk.com
<br /> PRODUCER
<br /> CUSTOMER ID:
<br /> INSURER(S)AFFORDING COVERAGE NAIC#
<br /> INSURED 2000700572 CP#1054 INSURER A: Nationwide Mutual Insurance Company 23787
<br /> Society for the Betterment of the Human Condi INSURER B:
<br /> DBA: Ligo Dojo of Budo Karate INSURER C:
<br /> 2518 A Millwood Court INSURER D:
<br /> Chapel Hill, NC 27514 INSURER E:
<br /> A Member of the Sports, Leisure&Entertainment RPG INSURER F:
<br /> COVERAGES CERTIFICATE NUMBER:2000316273 REVISION NUMBER:
<br /> THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.
<br /> NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE
<br /> ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF
<br /> SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br /> INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS
<br /> LTR INSD WVD (MM/DD/YYYY) (MM/DD/YYYY)
<br /> A X COMMERCIAL GENERAL LIABILITY X 6BMAS0000005853700 09/20/16 09/20/17 EACH OCCURRENCE $1,000,000
<br /> 12:01 AM 12:01 AM DAMAGE TO RENTED $500,000
<br /> CLAIMS-MADE X OCCUR PREMISES(Ea Occurrence)
<br /> MED EXP(Any one person) $5,000
<br /> PERSONAL&ADV INJURY $1,000,000
<br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $5,000,000
<br /> POLICY PROJECT LOC PRODUCTS–COMP/OP AGG $1,000,000
<br /> OTHER: PROFESSIONAL LIABILITY $1,000,000
<br /> LEGAL LIAB TO PARTICIPANTS $1,000,000
<br /> A AUTOMOBILE LIABILITY 6BMAS0000005853700 09/20/16 09/20/17 COMBINED SINGLE LIMIT(Ea $1,000,000
<br /> 12:01 AM 12:01 AM accident
<br /> ANY AUTO BODILY INJURY(Per person)
<br /> OWNED SCHEDULED
<br /> AUTOS ONLY AUTOS BODILY INJURY(Per accident)
<br /> HIRED NON-OWNED PROPERTY DAMAGE
<br /> X AUTOS ONLY X AUTOS ONLY (Per accident)
<br /> X Not provided while in Hawaii
<br /> UMBRELLA OCCUR
<br /> LIAB EACH OCCURRENCE
<br /> EXCESS LIAB -CLAIMS-MADE AGGREGATE
<br /> DED n RETENT-ION
<br /> WORKERS COMPENSATION N/A PER STATUTE' 'OTHER
<br /> AND EMPLOYERS'LIABILITY —
<br /> ANY PROPRIETOR/PARTNER/ Y/N E.L.EACH ACCIDENT
<br /> EXECUTIVE OFFICER/MEMBER
<br /> EXCLUDED?(Mandatory in NH) E.L.DISEASE–EA EMPLOYEE
<br /> If yes,describe under
<br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE–POLICY LIMIT
<br /> A MEDICAL PAYMENTS FOR PARTICIPANTS 09/20/16 09/20/17 PRIMARY MEDICAL
<br /> 6BMAS0000005853700 12:01 AM 12:01 AM
<br /> EXCESS MEDICAL $150,000
<br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
<br /> Location#1:630 Weaver Dairly Rd, Suite 107, Chapel Hill, North Carolina 27514; Location#2:2518 A Millwood Court, Chapel Hill, North Carolina 27514
<br /> Martial Arts style(s): Karate
<br /> The certificate holder is added as an additional insured, but only for liability caused, in whole or in part,by the acts or omissions of the named insured.
<br /> Sexual Abuse or Sexual Molestation Liability-$1,000,000 Each Occurrence(included above)/$1,000,000 Aggregate(included above)
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> Orange County SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
<br /> Attn: Risk Management EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH
<br /> 200 South Cameron Street THE POLICY PROVISIONS.
<br /> P.O. Box 8181
<br /> Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE
<br /> Sponsor � iF: :.��.,� -cam�
<br /> ©1988-2015 ACORD CORPORATION. All rights reserved.
<br /> Coverage is only extended to U.S.events and activities.
<br /> " 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.
<br /> ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
<br />
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