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EVAlVSTON 1NSUR.ANCE COMPANY <br />CERTIFICATE NO.: - <br />CERTIFICATE OF INSURANCE <br />EXCLUDES COVERAGE FOR NOMINEE EVENTS. SEE SEPARATE APPLICATIONS FOR NOMINEE EVENTS. <br />SPECIAL EVENT LIABILITY PROGRAM <br />PRODUCER: PUBLIC ENTITY (ADDITIONAL INSURED) <br /> C.~y a ~ Santa Ana <br />Driver Alliant Insurance Services M-28 <br />20 C~.v,t,c Centelc P.~aza <br />P. O. Box 28323 , <br />CA 92701 <br />Santa Ana <br />Santa Ana, CA 92799-8323 , <br />(949)660-8163 <br />License No: OC 36861 <br />NAMED INSURED (EVENT HOLDER): EVENT INFORMATION: <br />Bnau,~%a Mendez TYPE: IlvS~I.ue~,~ana,2 - Ml.us~c <br />2313 S. Rene DtI.%ve DATE(S): E/Ok/04 - 12/31/04 <br />Santa. Ana, CA 92704 LOCATION: ~.P _4aPvnrfnh C'oa7~'oh <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, terms 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 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 Limit 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 "occurrence" which takes place <br />after the event holder ceases to be a tenant in that premises. <br />OTHER ADDITIONAL INSUREDS <br /> <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 />AUTHORIZED REPRESENTATIVE: <br />DATE ISSUED: ~ / 18 / 0 4 <br />~, <br />