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6.H. -Paye 10 of 13 <br />A RU CERTIFICATE OF LIABILITY INSURANCE GATE(MWODIYYYY) <br />03/14/2019 <br />THIS CERTIFICATE 5 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 />RTA t e certificate holder is anADDITIONAL t e po Icy les must have L provisions or a 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 <br />K&K Insurance Group, Inc.F"Vmt: <br />1712 Magnavox Way <br />Fort Wayne 1N 46804 <br />CONTACT NAME:, Mass Merchandising Underwriting <br />FAX <br />o Ext): 800-426-2889 ,jq: 260-459-5105 <br />JAIC, No. <br />ortsinsurance-kk.cam s <br />ADDRESS: info @ P <br />CUSTOMER IM <br />INSURER(S) AFFORDING COVERAGE NAIL N <br />INSURED <br />Sequoia Booster Club <br />Sequoia HS Boosters Organization, 1201 Brewster Avenue <br />Redwood City, CA 94062 <br />A Member of the Sports, Leisure & Entertainment RPG <br />INSURER Nationwide Mutual Insurance Company 23787 <br />INSURER B: <br />INSURER C: <br />INSURER D: <br />INSURER E: <br />INSURER F: <br />COVERAGES CERTIFICATE NUMBER: W01401534 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 ES SUBJECT TO ALL THE TE=RMS, EXCLUSIONS AND CONDITIONS OF <br />SUCH POLICIES_ LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, <br />NSR <br />LTR <br />TYPE OF INSURANCE <br />[NSD <br />WVO <br />POLICY NUMBER <br />MMII)p <br />MM1DDIYYYY <br />LIMITS <br />A <br />X COMMERCIAL GENERAL LIABILITY <br />X <br />68RPG0000006420700 <br />04120/2019 <br />04/21/2019 <br />EACH OCCURRENCE $2,000,000 <br />sCLK S OCCUR <br />12:01 AM ED <br />11:01 AM <br />DAMAGE TO RENTED <br />PREMISES £a Occurrence $1,000,000 <br />MED EXP (Any one person) $5,000 <br />PERSONAL&ADV INJURY $2,000,000 <br />BENERAC'At3GREGATt? -. -.. . , <br />- a)OO;D00 <br />. <br />... <br />LAGGREGATE LIMITAPPLIES PER: <br />POtiCY JECT LOC <br />MIOTHER: <br />PRODUCTS - COMPIOP AGG $2,000,000PRO- <br />PROFESSIONAL LIABILITY <br />LEGAL LIAB TO PARTICIPANTS $2,000,000 <br />AUTOMOBILE LIABILITY <br />L <br />Ea accident <br />ANY AUTO <br />BODILY INJURY (Per person) <br />OWNED AUTOSHSCHFIDULEDBOD[LYIN3URY <br />AUTOS <br />PeraaidentONLY <br />l ) <br />HIRED NON -OWNED <br />PROPERTY l%99UE-- <br />Per accident <br />AUTOS ONLYAUTOS ONLY <br />NOT PROVIDED WHILE IN HAWAII <br />UMBRELLA UA13OCCUR <br />EACH OCCURRENCE <br />EXCESS LIAB CLAIMS -MADE <br />AGGREGATE _ <br />DED 71 RETENTION <br />WORKERS COMPENSATION ANIF D <br />EMPLOYERS' LIABILITY <br />NIA <br />STATUTE OTHER <br />ANY PROPRiETORIPARTNEW Y r N <br />E.L. EACH ACCIDENT <br />EXECUTIVE OFFICERIMEMBER <br />E.LDISEASE-EAEMPLOYEE <br />EXCLUDED? (Mandatary In NHE ❑ <br />If yes, describe under OESCRI PTION <br />OF OPERATIONS below <br />E.L- DISEASE- POLICY LIMIT <br />A <br />MEDICAL PAYMENTS FOR PARTICIPANTS <br />68RP130000006420700 <br />04120=19 <br />04121/2019 <br />PRIMARY MEDICAL <br />I <br />12:01 AM EDT <br />12:01 AM <br />EXCESS MEDICAL $25,000 <br />DESCRIPTION OF OPERATIONS I LOCATIONS) VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />Legal Liability to Participants (LLP) limit is a per occurrence limit. <br />Event Name: Sequoia Stampede Type of Event: Walk and Run Distance:5K <br />Event Date (including ancillary events and set-upAear-down): 412012019 to 412012019 Number of Participants: 330 Event Location: Sequoia High School <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 />4CK I iriCA 1 t HOLDER CANCELLATION <br />City -insureds <br />1301 Maple Street <br />Redwood City, CA 94063 <br />SHOULD ANTZMWE A80VE DESCRIBED BE EANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />(Co -promoter) <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 />ACORD 25 (201G03) p 1988-2015 ACORD CORPORATION. All rights reserved, <br />The ACORD name and logo are registered marks of ACORD <br />171 <br />