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EVANSTON INSURANCE 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: <br />PUBLIC ENTITY (ADDITIONAL INSURED) <br />Driver Alliant Insurance ServicesR-"a-�'v ��2 <br />City o b Santa. Ana <br />P.O.Box 26323 ,j�j•^ pC� <br />20 Civic Centim P.eaza, M-28 <br />Santa Ana, CA 92799-8323 Iy al f 4- <br />Santa Ana, CA 92701 <br />(949) 660-8163 <br />�^ <br />License No: OC 36861 <br />NAMED INSURED (EVENT HO ): <br />p p <br />ANT �O gMi nTST?Nuc ti.onak-Tae Kwon Do* <br />Choa Le <br />TYPE: <br />4 FabAi.an0 <br />DATE(S): 1 /01 /05 - 12/31/05 <br />Dtv.fne, CA 92620 <br />LOCATION: Rafaadn Centro <br />*Non Contact <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: 05SEPI0000oi <br />MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2005 EXPIRATION: JANUARY 1, 2006 <br />COMMERCIAL GENERAL LLA131UTY <br />OCCURRENCEFORM <br />DEDUCTIBLE: NONE <br />General Aggregate limit $ 2po0,000 <br />Products & Completed Operations 11000,000 <br />Personal & Advertising Injury 11000,000 <br />Fach Occurrence Limit 11000,000 <br />Fin 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 e L <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 doss not apply to: Any "occummm" 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 />AUTHORIZED REPRESENTATIVE: Z� � <br />DATE ISSUED: <br />