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<br />EVANSTON 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 />PRODUCER: PUBUC ENTITY (ADDITIONAL INSURED) <br />Driver Allilljlt Insurance Services Cay 0 n San-ta. Ana <br />P. O. Box 28323 20 C~v~e Cent~ Plaza, M-28 <br />Santa Ana, CA 92799-8323 San-ta. AM, CA 92701 <br />(949) 660-8163 <br />License No: OC 36861 <br />NAMED INSURED (EVENT HOLDER): EVENT INFORMATION: <br />CaYlde.i.aJU.o Lopez N -'?'005 -00'1 TYPE: r Y/.6Vtu.c;UoYlal - B~elfele. Sat\e.:ty <br />DATE(S): 2/07 /05- 6/30/05 <br /> LOCATION: V aJU.o u.6 <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 isaued 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: 05SEPIOOOOOI <br />MASTER POLICY DATES: EFFECTIVE: JANUARY 1,2005 EXPIRATION: JANUARY 1,2006 <br />COMMERCIAL GENERAL LIABIUTY OCCURRENCE FORM DEDUcrmlE: NONE <br />General Aggregate Limit $ 2,000.000 <br />Products & eon.>leted Openalions 1,000,000 <br />Penortal &: Advertising Injury 1.000,000 <br />Each Occ:wrcncc Limit 1,000.000 <br />Fin: Dama.. (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 orpnizatim shown in this schedule, but only with respect to liability arisms out of the <br />ownership, maintenance or use of tile premises used by the named lnsurcd (event holder). This insurance does not apply to: Any .'occummce" which takes place <br />aftcrthc event holder ceases b)'be a tenant in thatprcmises. <br /> OTHER ADDmONAL INSUREDS <br /> APPROVED AS TO fe, , <br /> \ iiv; 'Jl... <br /> -r >6" ,7 ,,(' <br /> ';;;:lw<', u" <br /> Assistant City/Ai ,,-,! I <br />CANCEl LA. TION. Should the above described po1icy 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 />U~~ <br /> <br />DATE ISSUED, <br /> <br />2/07/05 <br />