Loading...
2021/08/01 Julie Ann Werhnyak DBA Artemis Self-Defense LLC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/ DD/ YYYY) 09/14/2021 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). PRODUCER SADLER & COMPANY, INC. P.O. BOX 5866 COLUMBIA, SOUTH CAROLINA 29250-5866 CONTACT NAME: Sports Dept PHONE (A/ C, No. Ext): 800-622-7370   |   FAX (A/ C, No): 803-256-4017 E- MAIL ADDRESS: instructor@sadlersports.com PRODUCER CUSTOMER ID#: INSURED Julie Ann Werhnyak DBA Artemis Self- Defense LLC. 1717 E. Morten Ave. 44 Phoenix, AZ 85020 Application ID: 329831 A Member of the Sports, Leisure & Entertainment RPG INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Nationwide Mutual Insurance Company INSURER B: INSURER C: INSURER D: COVERAGES CERTIFICATE NUMBER 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 INSD SUBR WVD POLICY NUMBER POLICY EFF (MM/ DD/ YYYY) POLICY EXP (MM/ DD/ YYYY) LIMITS A COMMERCIAL GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY    CLAIMS MADE   OCCUR ____________________ ____________________ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY   PROJECT   LOC OTHER X   6BRPG00000074469 12:01AM ET 08/01/2021 12:01AM ET 08/01/2022 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence)$1,000,000 MEDICAL EXP (Any one person)$5,000 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $5,000,000 PRODUCTS- COMP/ OP AGG $1,000,000 PROFESSIONAL LIABILITY $1,000,000 LEGAL LIAB TO PARTICIPANTS $1,000,000 AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON- OWNED AUTOS NOT PROVIDED WHILE IN HAWAII    COMBINED SINGLE LIMIT (Ea Accident)  BODILY INJURY (Per person)  BODILY INJURY (Per accident)  PROPERTY DAMAGE (Per accident)          UMBRELLA LIAB   OCCUR EXCESS LIAB   CLAIMS- MADE DEDUCTIBLE RETENTION    EACH OCCURRENCE   AGGREGATE        WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR / PARTNER / EXECUTIVE OFFICER / MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below    N/ A PER STATUE OTHER   E.L. EACH ACCIDENT   E.L. DISEASE - EA EOMPLOYEE   E.L. DISEASE - POLICY LIMIT     MEDICAL PAYMENTS FOR PARTICIPANTS    PRIMARY MEDICAl   EXCESS MEDICAL   DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: Instruction of - Martial Arts Type - Other, Self- Defense / Law Enforcement / Security Instructor(Law Enforcement Defensive Tactics) 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. CERTIFICATE HOLDER CANCELLATION RELATIONSHIP: Property Owner/ Lessor City of Menifee 29844 Haun Road Menifee,, CA 95286 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Coverage is only extended to U.S. events and activities ** 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. ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD --- Y/ N DocuSign Envelope ID: EF1C6F03-EEB5-4B84-94FC-5B91725FC4E6 --- ISO | Commercial General Liability Forms | 07/01/04 POLICY NUMBER: 6BRPG00000074469 COMMERCIAL GENERAL LIABILITY INSURED: Julie Ann Werhnyak CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE 1. Name of Additional Insured Person(s) or Organizations(s): City of Menifee 29844 Haun Road Menifee,, CA 95286 (Information required to complete this Schedule, if not shown above, will be shown in the Declarations.) A. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Date Added: 07/30/2021 04:13:29 PM CG 20 26 04 13 Page 1 of 1 Copyright. Insurance Services Office, Inc., 2012 DocuSign Envelope ID: EF1C6F03-EEB5-4B84-94FC-5B91725FC4E6