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PROFESSIONAL LIABILITY CERTIFICATE OF INSURANCE <br /> CLAIMS MADE FORM Page: 1 of 1 <br /> Agent Information Certificate#: 201706206 <br /> Vicencia&Buckley A Division of HUB International Member#: 169699 <br /> Insurance Services <br /> 6 Centerpointe Drive,#350 Effective Date: 07/1 <br /> La Palma,CA 90623-2538 Expiration Date: 6/30/2017 1 2:01:00 AM <br /> (714)739-3177 FAX (714)739-3188 90 DAY DISCOVERY PERIOD <br /> (800)223-9998 <br /> License#: 151305 Policy issued by Lexington Insurance Company <br /> Insured's Name and Mailing Address: Policy#: 014266055 <br /> DONER,FERENC, E <br /> 919 OLYMPIC AVE <br /> EDMONDS,WA, 98020 <br /> Type of Insurance: Professional Liability-Claims Made Form <br /> COVERAGE: Insured's Status:Instructor <br /> COMBINED SINGLE LIMIT: $1,000,000 (per occurrence) Equipment Liability: Not Included <br /> ANNUAL AGGREGATE: $2,000,000 Cylinder Coverage: Not Covered <br /> Retroactive Date: 7/14/2016,or the first day of uninterrupted coverage,whichever is earlier(refer to section VI of the policy). However,in the event of <br /> a claim which invokes a Retroactive Date prior to 7/14/2016,the Certificate Holder must submit proof of uninterrupted insurance coverage dating prior <br /> to the date that the alleged negligent act,error,or omission occurred. <br /> Physical Address is the same as the mailing address <br /> The insurance afforded by this policy is a master policy issued to PADI Worldwide Corporation,30151 Tomas Street, Rancho Santa Margarita,CA <br /> 92688.The insurance is provided under terms and conditions of the master policy which is enclosed with this certificate. Please read the policy for a <br /> full description of the terms,conditions and exclusions of the policy.This certificate does not amend,alter or extend the coverage afforded by the <br /> policy referenced on this certificate. <br /> Notice of cancelation:The premium and any taxes or fees are fully earned upon inception and no refund is granted unless cancelled by the company. <br /> If the company cancels this policy,45 days notice will be given to the certificate holder unless cancellation is for nonpayment of premium,then 10 <br /> days notice will be provided,and any premium not earned will be returned to the certificate holder. <br /> "THIS CONTRACT IS REGISTERED AND DELIVERED AS A SURPLUS LINE COVERAGE <br /> UNDER THE INSURANCE CODE OF THE STATE OF WASHINGTON, TITLE 48RCW. IT IS NOT <br /> PROTECTED BY ANY WASHINGTON STATE GUARANTY ASSOCIATION LAW." <br /> Issued on behalf of: Authorized Representative <br /> Lexington Insurance Company <br /> -twit <br /> Steve Vicencia CPCU <br />