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ACORD 25 (2016/03) <br />The ACORD name and logo are registered marks of ACORD <br />© 1988-2015 ACORD CORPORATION. All rights reserved. <br /> <br />CERTIFICATE OF LIABILITY INSURANCE <br /> <br />DATE (MM/DD/YYYY) <br />06/29/2019 <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 />Kevin Kirk <br />605 Eastowne Drive, Suite C <br />Chapel Hill, NC 27514 <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: W01473925 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 X 6BRPG0000006940500 08/21/2019 <br />12:01 AM EDT <br />08/21/2021 <br />12:01 AM <br />EACH OCCURRENCE $1,000,000 <br /> CLAIMS- <br />MADE X OCCUR DAMAGE TO RENTED <br />PREMISES (Ea Occurrence)$1,000,000 <br /> MED EXP (Any one person)$5,000 <br /> PERSONAL & ADV INJURY $1,000,000 <br /> GENERAL AGGREGATE per year $5,000,000 <br />GEN’L AGGREGATE LIMIT APPLIES PER:PRODUCTS – COMP/OP AGG per year $1,000,000 <br /> POLICY PRO- <br />JECT LOC PROFESSIONAL LIABILITY $1,000,000 <br /> OTHER: LEGAL LIAB TO PARTICIPANTS $1,000,000 <br /> AUTOMOBILE LIABILITY <br /> <br /> <br /> <br />COMBINED SINGLE LIMIT <br />(Ea accident) <br /> ANY AUTO BODILY INJURY (Per person) <br /> OWNED AUTOS <br />ONLY SCHEDULED <br />AUTOS BODILY INJURY (Per accident) <br /> HIRED <br />AUTOS ONLY 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 /> WORKERS COMPENSATION AND <br />EMPLOYERS’ LIABILITY <br /> <br />ANY PROPRIETOR/PARTNER/ <br />EXECUTIVE OFFICER/MEMBER <br />EXCLUDED? (Mandatory in NH) <br /> <br />If yes, describe under DESCRIPTION <br />OF OPERATIONS below <br /> <br /> <br />N/A PER <br />STATUTE OTHER <br />Y / N E.L. EACH ACCIDENT <br /> E.L. DISEASE – EA EMPLOYEE <br /> E.L. DISEASE – POLICY LIMIT <br /> MEDICAL PAYMENTS FOR PARTICIPANTS <br /> <br /> <br /> <br />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 />Certified Instructor of: Exercise, 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 />County of Orange, North Carolina <br />200 S. Cameron Street, Box 8181 <br />Hillsborough, NC 27278 <br />(Owner/Lessor of Premises) <br />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 /> <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: 621BDE94-D1B6-4C63-B952-C581D075EF1E