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CERTIFICATE OF LIABILITY INSURANCE

DATE (MM/DDNYYY)

12/20/2012

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 ~2~I~CT

David

Wood
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(602)230-8207

The 4835 Suite

Wood East 440

Insurance Cactus

Group, Road AZ

Inc.

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(602)230-8200 davidw@woodinsurancegroup.
INSURER(S) AFFORDING COVERAGE

com
NAIC#

Scottsdale
INSURED

85254

INSURER A INSURERB:

Liberty

Surplus

Insurance

Joyce 27124 Kent

Song 20th

Kim

LAc South WA 98032

INSURERC: INSURERD: INSURERE: INSURERF:

Place

COVERAGES

CERTIFICATE NUMBER:CL12122044590

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 UBR POLICY NUMBER II~gM%f.!W'v.. 11~~L6<f>~ EACH OCCURRENCE GENERAL LIMITS

A -

GENERAL

LIABILITY LIABILITY OCCUR

$
$

1,000,000 N/A N/A N/A 5,000,000 N/A

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:i:JMMERCIAL

CLAIMSMADE

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~1000414-0113

rz/l/2013

rz/l/2014

MED EXP (Anyone PERSONAL GENERAL

person)

$ $ $

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Med Prof Liability

& ADV INJURY AGGREGATE COMP/OP AGG

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GEN'L AGGREGATE POLICY

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LIABILITY ,--

LIMIT APPLIES

PER: LOC

PRODUCTS

$ $

AUTOMOBILE

~~~~~~~tfINGLE

LIMIT

$ $ $ $

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ANY AUTO ALL OWNED AUTOS HIRED AUTOS

BODILY INJURY (Per person)

f--f---

SCHEDULED AUTOS NONOWNED AUTOS

BODILY INJURY (Per accident) rp~~~;'~d~t~AMAGE

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UMBRELLA EXCESSLIAB DED

LIAB

H
$

$
OCCUR CLAIMSMADE EACH OCCURRENCE AGGREGATE $

$
$

I I

RETENTION

WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below

0
Y/N

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I N/A E.L. EACH ACCIDENT E.L DISEASE

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$
$ $

- EA EMPLOYE

E.L. DISEASE - POLICY LIMIT

DESCRIPTION

OF OPERATIONS

/ LOCATIONS

/ VEHICLES

(Attach

ACORD

101, Additional

Remarf<s Schedule,

if more space is required)

Covered Covered Covered Covered Coverage

Provider: Specialty: Provider: Specialty: is for

Joyce

Song

Kim,

LAc; LAc;

Retroactive Retroactive of the

Date: Date: named

03/11/1998 12/05/1997 insured.

Acupuncture Nam Hoon Kim, Acupuncture services provided

on behalf

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.

No

Certificate

Holder

AUTHORIZED

REPRESENTATIVE

,
ACORD 25 (2010105)
INS025
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David

Wood/NIB

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1988-2010 ACORD CORPORATION. All rights reserved.

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