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<br /> <br />EVANSTON JNSURANCE COMPANY <br />CERTIFICATE NO.: <br /> <br />CERTIFICATE OF INSURANCE <br />EXCLUDES COVERAGE FOR NOMINEE EVENTS. SEE SEPARATE APPLICATIONS FOR NOMINEE EVENTS. <br />SPECIAL EVENT LIABILITY PROGRAM <br /> <br />PRODUCER: <br /> <br />PUBLIC ENTITY (ADDITIONAL INSURED) <br /> <br />Driver Alliant Insurance Services <br />p, O. Box 28323 <br />Santa Ana, CA 92799-8323 <br />(949) 660-8163 <br />License No: OC 36861 <br />NAMED INSURED (EVENT HOlDER): <br />A!:>{' .,., I J ç <br />¡.J -';;>i ,(.'/'-~ ,-",,) <br /> <br />Daniel Achacz ' 10 - ,:-IOL'3., (J 7/ <br />, - {'.II 0 <br />Iv. ,:),(;[7,). - , ró <br /> <br />City of Santa Ana <br />20 Civic Center Plaza, <br />P.O. Box 1988 <br />Santa Ana, CA 92702 <br /> <br />M-28 <br /> <br />EVENT INFORMATION: <br />TYPE: Self Improvement <br />DATE(S): 1/14/04 - 12/31/04 <br />LOCATION: S.A. Jail <br /> <br />This is to certify that the policies of insurance listed below have been issued to the insured named above for the policy period <br />indicated, Notwithstanding any requirements, tenns or conditions of any contract or other document with respect to which this <br />certificate may be issued or may pertain, the insurance afforded by the policies described herein is subject to all the terms, <br />exclusions and conditions of such policies. Limits shown may have been reduced by paid claims. <br />INSURANCE CARRIER: Evanston Insumnce Company <br /> <br />MASTER POLICY NUMBER: 04SEPIOOOOOI <br /> <br />MASTER POLICY DATES: EFFECTIVE: JANUARY 1,2004 <br /> <br />EXPIRATION: JANUARY I, 2005 <br /> <br />COMMERCIAL GENERAL LIABILITY <br />General Aggregatt Ljrrrit <br />Products & COJr(Jleted Operations <br />Personal & Advertjsing Injury <br />Each Occunence Limit <br />Fire Damage (Any One Fire) <br />Medical Payments (Any One Person) <br /> <br />OCCURRENCE FORM <br /> <br />DEDUCTIBLE: NONE <br /> <br />$ 2,000,000 <br />1,000,000 <br />1,000,000 <br />1.000,000 <br />50,000 <br />5,000 <br /> <br />The limits of insurance apply separately to each event insured by this policy as if a separate policy of insurance has been issued for that event. <br />"Who is insured" is amended to include, as an insured. the person or organization shown in ,this schedule, but only witb respect to liability arising out of the <br />ownership. maintenance or use of the premises used by the named insured (event holder). This insurance does not apply to: Any "occUlTeßCe" which takes place <br />after the event holder ceases to be a tenant in that premises. <br />OTHER ADDmONAL INSUREDS <br /> <br />CANCEI.LA TION: Should the above described pOljc:y to cancelled before the expiration date thereof, the issuing company will mail 30 days written notice 10 the <br />certificate holder and additional insureds listed. <br /> <br />AUTIiORIZED REPRESENTATIVE: ~~ <br />DATE ISSUED: January 14, 2004 <br /> <br />X;;~r?L7 <br />