2021-501-E-DEAPR-Nishith Trivedi-Martial Arts Instruction

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CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 6/27/2021 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). CONTACTNAME: PHONE(A/C, No, Ext):FAX(A/C, No):(630) 665-7291 E-MAIL ADDRESS:Dmbark@fdean.com INSURER(S) AFFORDING COVERAGE NAIC # PRODUCER Francis L. Dean 12800 University Drive Suite 125 Fort Myers, FL 33907 fdean.com INSURER A :U.S. Fire Insurance Company 21113 INSURER B : INSURER C : INSURER D : INSURER E : INSURED SPORTS AND RECREATION PROVIDERS ASSOCIATION (PURCHASING GROUP) AND ITS PARTICIPATING MEMBERS: TIGER PASARYU MARTIAL ARTS DBA NISHITH TRIVEDI 318 CLARKSON RIDGE LANE HILLSBOROGH, NC 27278 INSURER F : COVERAGES CERTIFICATE NUMBER:USP333591 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 LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY)LIMITS GENERAL LIABILITY GENERAL AGGREGATE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY PRODUCTS - COMP/OP AGG $ 2,000,000 CLAIMS-MADE X OCCUR PERSONAL & ADV INJURY $ 1,000,000 EACH OCCURRENCE $ 1,000,000 X INCLUDES ATHLETIC PARTICIPANTS FIRE DAMAGE (Any one fire)$ 300,000 GEN'L AGGREGATE LIMIT APPLIES PER:$ A X POLICY PRO- JECT LOC X SRPGAPML-101-0720 4/1/2021 12:01 AM 4/1/2022 12:01 AM AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident)$ ANY AUTO BODILY INJURY (Per person)$ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident)$ HIRED AUTO NON-OWNED AUTOS PROPERTY DAMAGE (Per accident)$ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $$ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N WC STATU- TORY LIMITS OTH - ER $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED?E.L. EACH ACCIDENT $ (Mandatory in NH)E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below N / A E.L. DISEASE - POLICY LIMIT $ A Accident/Medical Coverage US1328688 4/1/2021 12:01 AM 4/1/2022 12:01 AM AD&D AGGREGATE AD&D MAXIMUM MEDICAL DEDUCTIBLE TERMS OF PAYMENT $ 500,000 $ 100,000 $ 100,000 $ 250 EXCESS DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Covered activities: Martial Arts.Locations: 318 Clarkson Ridge Lane, Hillsborogh NC 27278. Certificate Holder is named as additional insured with respect to the operations of the Named Insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ORANGE COUNTY, NC PO BOX 8181 HILLSBOROGH, NC 27278 AUTHORIZED REPRESENTATIVE Francis L. Dean © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05)The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID: 291E7050-F04D-4DFF-97C0-FD47264248C9