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ACORD 25 (2016/03)The ACORD name and logo are registered marks of ACORD © 1988-2015 ACORD CORPORATION. All rights reserved. <br />CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) <br />06/16/2018 <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 endorsement(s). <br />PRODUCER CONTACT NAME:Mass Merchandising Underwriting <br />K&K Insurance Group, Inc. <br />1712 Magnavox Way <br />Fort Wayne IN 46804 <br />PHONE <br />(A/C, No, Ext):1-800-506-4856 FAX <br />(A/C, No):1-260-459-5590 <br />E-MAIL <br />ADDRESS:info@fitnessinsurance-kk.com <br />PRODUCER <br />CUSTOMER ID: <br />INSURER(S) AFFORDING COVERAGE NAIC # <br />INSURED INSURER A:Nationwide Mutual Insurance Company 23787 <br />Arlene Bynum <br />DBA: Arlene Bynum <br />4816 Barbee Road <br />Durham, NC 27713 <br />A Member of the Sports, Leisure & Entertainment RPG <br />INSURER B: <br />INSURER C: <br />INSURER D: <br />INSURER E: <br />INSURER F: <br />COVERAGES CERTIFICATE NUMBER: W01253228 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 TYPE OF INSURANCE ADDL <br />INSD <br />SUBR <br />WVD POLICY NUMBER POLICY EFF <br />(MM/DD/YYYY) <br />POLICY EXP <br />(MM/DD/YYYY)LIMITS <br />A X COMMERCIAL GENERAL LIABILITY 6BRPG0000006255600 06/18/2018 <br />12:01 AM EDT <br />06/18/2019 <br />12:01 AM <br />EACH OCCURRENCE $500,000 <br />CLAIMS- <br />MADE X OCCUR DAMAGE TO RENTED <br />PREMISES (Ea Occurrence)$500,000 <br />MED EXP (Any one person)$5,000 <br />PERSONAL & ADV INJURY $500,000 <br />GENERAL AGGREGATE $5,000,000 <br />*(1¶/$**5(*$7(/,0,7$33/,(63(5352'8&76±&20323$**$500,000 <br />POLICY PRO- <br />JECT LOC PROFESSIONAL LIABILITY $500,000 <br />OTHER:LEGAL LIAB TO PARTICIPANTS $500,000 <br />AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT <br />(Ea accident) <br />ANY AUTO BODILY INJURY (Per person) <br />OWNED AUTOS <br />ONLY <br />SCHEDULED <br />AUTOS BODILY INJURY (Per accident) <br />HIRED <br />AUTOS ONLY <br />NON-OWNED <br />AUTOS ONLY <br />PROPERTY DAMAGE <br />(Per accident) <br />NOT PROVIDED WHILE IN HAWAII <br />UMBRELLA LIAB OCCUR EACH OCCURRENCE <br />EXCESS LIAB CLAIMS-MADE AGGREGATE <br />DED RETENTION <br />:25.(56&203(16$7,21$1' <br />(03/2<(56¶/,$%,/,7< <br />ANY PROPRIETOR/PARTNER/ <br />EXECUTIVE OFFICER/MEMBER <br />EXCLUDED?(Mandatory in NH) <br />If yes, describe under DESCRIPTION <br />OF OPERATIONS below <br />N/A PER <br />STATUTE OTHER <br />Y / N E.L. EACH ACCIDENT <br />(/',6($6(±($(03/2<(( <br />(/',6($6(±32/,&</,0,7 <br />MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL <br />EXCESS MEDICAL <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />$EXVH0ROHVWDWLRQ+DUDVVPHQWRU6H[XDO&RQGXFW'HIHQVH&RVW5HLPEXUVHPHQW±/LPLW <br />Certified Instructor of: Aerobics, Personal training <br />CERTIFICATE HOLDER CANCELLATION <br />Evidence of Coverage SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <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 />DocuSign Envelope ID: AAB8A729-BEDF-4F5C-9AAD-7D449E68FC28