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DocuSign Envelope ID: 79D22E78- DB65 -4DA4- 8933- 18D1930A50B7 <br />AC"R" CERTIFICATE OF LIABILITY INSURANCE <br />DATE(MM /DD /YYYY) <br />ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF <br />06/27/2017 <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 REPRESENTATIVE <br />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. If <br />SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this <br />certificate does not confer rights to the certificate holder in lieu of such endorsements . <br />PRODUCER <br />CONTACT NAME: Mass Merchandising Underwriting <br />K &K Insurance Group, Inc. <br />1712 Magnavox Way <br />Fort Wayne IN 46804 <br />PHONE 1- 800 - 506 -4856 FAx 1- 260- 459 -5590 <br />E A Lo, Ext A/C, No <br />: <br />ADDRESS: info @fitnessinsurance - kk.com <br />PRODUCER <br />6BRPG0000006028600 <br />CUSTOMER ID: <br />INSURER(S) AFFORDING COVERAGE <br />NAIC # <br />$1,000,000 <br />INSURED <br />INSURER A: Nationwide Mutual Insurance Company <br />23787 <br />Kevin James Kirk <br />INSURER B: <br />12:01 AM EDT <br />DBA: Functional Fitness <br />5311 Beaumont Drive <br />INSURER C: <br />DAMAGE TO RENTED <br />PREMISES Ea Occurrence <br />INSURER D: <br />Durham, NC 27707 <br />INSURER E: <br />A Member of the Sports, Leisure & Entertainment RPG <br />INSURER F: <br />COVERAGES CERTIFICATE NUMBER: W01055915 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 <br />LTR <br />TYPE OF INSURANCE <br />ADDL <br />INSD <br />SUBR <br />WVD <br />POLICY NUMBER <br />POLICY EFF <br />MM /DD/YYYY <br />POLICY EXP <br />MM /DD/YYYY <br />LIMITS <br />A <br />X <br />COMMERCIAL GENERAL LIABILITY <br />X <br />6BRPG0000006028600 <br />08/21/2017 <br />08/21/2019 <br />EACH OCCURRENCE <br />$1,000,000 <br />CLAIMS- <br />MADE � OCCUR <br />12:01 AM EDT <br />12:01 AM <br />DAMAGE TO RENTED <br />PREMISES Ea Occurrence <br />$300,000 <br />MED EXP (Any one person) <br />$5,000 <br />PERSONAL & ADV INJURY <br />$1,000,000 <br />GENERAL AGGREGATE <br />per year $5,000,000 <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />PRODUCTS – COMP /OP AGG <br />per year $1,000,000 <br />POLICY r-1 E� —1 LOC <br />PROFESSIONAL LIABILITY <br />$1,000,000 <br />OTHER: <br />LEGAL LIAB TO PARTICIPANTS <br />$1,000,000 <br />AUTOMOBILE LIABILITY <br />COMBINED SINGLE LIMIT <br />Ea accident <br />BODILY INJURY (Per person) <br />ANY AUTO <br />OWNED AUTOS SCHEDULED <br />ONLY AUTOS <br />BODILY INJURY (Per accident) <br />HIRED NON -OWNED <br />PROPERTY DAMAGE <br />AUTOS ONLY AUTOS ONLY <br />Per accident <br />NOT PROVIDED WHILE IN HAWAII <br />UMBRELLA LIAB OCCUR <br />EACH OCCURRENCE <br />EXCESS LIAB CLAIMS -MADE <br />AGGREGATE <br />DED RETENTION <br />WORKERS COMPENSATION AND <br />EMPLOYERS' LIABILITY <br />N/A <br />PER OTHER <br />STATUTE <br />ANY PROPRIETOR /PARTNER/ Y / N <br />E.L. EACH ACCIDENT <br />EXECUTIVE OFFICER /MEMBER El EXCLUDED? (Mandatory in NH) <br />E.L. DISEASE – EA EMPLOYEE <br />E.L. DISEASE – POLICY LIMIT <br />If yes, describe under DESCRIPTION <br />OF OPERATIONS below <br />MEDICAL PAYMENTS FOR PARTICIPANTS <br />PRIMARY MEDICAL <br />EXCESS MEDICAL <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />Certified Instructor of: Personal training, Strength <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 />CERTIFICATE HOLDER CANCELLATION <br />Orange County, NC <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />200 S. Cameron St., P.O. Box 8181 <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />Hillsborough, NC 27278 <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />(Owner /Lessor of Premises) <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) © 1988 -2015 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />