2019-524-E DEAPR - Nishith Trivedi martial arts instruction

Browse Search

DocuSign Envelope ID: EAD61387-EOF3-42A1-B144-F5D636C155C1 "4 n� CERTIFICATE OF LIABILITY INSURANCE FA 12/2019YY) 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 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 Francis L. Dean NAME: OE FAX, 12800 University Drive A/C,NNo,Ext: ,q/C No): (630)665-7291 Suite 125 E-MAIL ADDRESS: Dmbark@fdean.com Fort Myers, FL 33907 INSURER(S)AFFORDING COVERAGE NAIC# fdean.com INSURERA: U.S.Fire Insurance Company 21113 INSURED SPORTS AND RECREATION PROVIDERS ASSOCIATION(PURCHASING GROUP)AND INSURERB: ITS PARTICIPATING MEMBERS: INSURERC: TIGER PASARYU MARTIAL ARTS DBA NISHITH TRIVEDI INSURERD: 622 CHILDSBURGH WAY INSURERE: HILLSBOROGH, INC 27278 INSURERF: COVERAGES CERTIFICATE NUMBER: USP290745 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 INSR WVD MM/DD/YYYY MM/DD/YYYY GENERAL LIABILITY GENERAL AGGREGATE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG $ 2,000,000 CLAIMS-MADE FX]OCCUR PERSONAL&ADV INJURY $ 1,000,000 1 2:01 A X SRPGAPML-101-0718 2:01 19 AM 122:01:01 20 AM EACH OCCURRENCE $ 1,000,000 X INCLUDES ATHLETIC PARTICIPANTS FIRE DAMAGE(Any one fire) $ 300,000 GEN'L AGGREGATE LIMIT APPLIES PER: $ X POLICY PRO- ECT LOC J A COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTO NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below AD&D $500,000 A Accident/Medical Coverage US1032069 4/1/2019 4/1/2020 MAXIMUM MEDICAL $100,000 12:01 AM 12:01 AM DEDUCTIBLE $250 TERMS OF PAYMENT EXCESS DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Covered activities: Martial Arts. Locations: 622 Childsburgh Way, Hillsborogh NC 27278. Certificate Holder is named as additional insured with respect to the operations of the Named Insured. CERTIFICATE HOLDER CANCELLATION ORANGE COUNTY, NC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE PO BOX 8181 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. HILLSBOROGH, NC 27278 AUTHORIZED REPRESENTATIVE Fra n r i, L. D eaw ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD