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<br />- <br /> <br />EV ANSTON INSURANCE 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 /> <br />PRODUCER: PUBLIC ENTITY (ADDITIONAL INSURED) <br />Driver Alliant Insurance Services Cay 06 Sa.n..ta. Ana. <br />P. O. Box 28323 20 C'¿v'¿c. CeYt:t.eA Plaza., M-28 <br />Santa Ana, CA 92799-8323 Sa.n:t.a. Ana., CA 92101 <br />(949) 660-8163 <br />License No: OC 36861 <br />NAMED INSURED (EVENT HOLDER): 1- EVENT INFORMATION: <br />Tom Wa.l:te.tl4 ¡J - ;;?OéJ -o4g' TYPE: In6~uc.tiona.i-Setn ImpJr..ovemeYt:t. <br />301 N. FOJr..d Ave.nue, #106 DA TE(S): 6/15/04 - 12/31/04 <br />F u.U.eJLto n, CA 92832 LOCATION: Sou:thwe-ld Se.n.Æ..oJr.. Ce.n:te.Jr.. <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. Linúts shown may have been reduced by paid claims. <br />INSURANCE CARRIER: Evanston Insurance Company <br />MASTER POLICY NUMBER: 04SEP1000001 <br />MASTER POLICY DATES: EFFECTIVE: JANUARY 1,2004 EXPIRATION: JANUARY 1,2005 <br />COMMERCIAL GENERAL LIABILITY OCCURRENCE FORM DEDUCTIBLE: NONE <br />General Aggregate Limit $ 2,000,000 <br />Products & Completed Operations 1,000,000 <br />Personal & Advertising Injury 1,000,000 <br />Each Occurrence Lirnit 1,000,000 <br />Fire Damage (Any One Fire) 50,000 <br />Medical Payments (Any One Person) 5,000 <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 with 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 "occUlTence" which takes place <br />after the event holder ceases to be a tenant in that premises. <br /> OTHER ADDITIONAL INSUREDS <br />CANCELLATION: Should the above described policy to cancelled before the expiration date thereof, the issuing company will mail 30 days written notice to the <br />certificate holder and additional insureds listed. <br /> <br />AUTHORIZED REPRESENTATIVE: ~~ <br /> <br />DATE ISSUED: Ma.y 12, 2004 <br /> <br />.P ¥ <br />I' (M,v11Â- ç;h-7 <br />