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<br />EY ANSTON INSURANCE COMPANY <br />CERTIfiCATE NO.: <br /> <br />CERTlFICA TE 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 A1IiaDt 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 />EJUc. M. SelUe /V-J,/)(y!-o<}&l.. <br />516 W. 17th S~eet, HC <br />Santa. AM, CA 92106 <br /> <br />CUy o~ Sa.l1.t4 Ana. <br />20 Civ-ic, Cen.tVl Plo.za., M-28 <br />Sa.n.ta. Ana., CA 92707 <br /> <br />This is to certify that the policies of il1Slllance listed below ha ve 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 descnbed herein is subject to al/ 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 /> <br />MASTER POLICY NUMBER: 04SEPIOooool <br /> <br />MASTER POLICY DATES: EFFECTIVE: JANUARY 1,2004 EXPIRATION: JANUARY I, 2005 <br /> <br />EVENT INFORMATION: <br />TYPE: l-IonP1"h II f:it-MH _ T"A.thfl~;Uona~ <br />DATE{S): r; /g /nd _ T9/~1In4 <br />LOCAnON: L':"u'!4' '1~r{le{l(J3 <:~~tll'" <br /> <br />COMMERCIAL GENERAL LIABILITY <br />General Agvegate Limit <br />Products &; Completed Operations <br />l>>erso.nal & Advertisine Injwy <br />Eac'h Occurrence Limit <br />Fire Damage (Any One Fire) <br />ModicAJ Fa)'TllCnlS (Any One Person) <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 />OCCURRENCE FORM <br /> <br />DEDUCTIBLE, NONE <br /> <br />The limilS of insuroncc apply scpar.llely to each ""ent i_red by this policy as if. """,,Ie policy of insuroncc h.. been issued for that evCllt. <br />"Who is insured" is "nendod 10 include, as an illSUred, the person or OlpJIUation shown in this schedule. hot only wilh ""Peet to !iabHity ansing out ofthe <br />nWl>eBhip, maintenance or use of the premises u'Cd by the named insured (eve", holder). This insuranee does not apply to, Any "occurrence" which takes place <br />after the eVent bolder ceases to be a tenant in that premises. <br />OTHER ADDITIONAL INSUREDS <br /> <br />CANcm t A TtOl<: Should the ahove de..n"hed policy to cancelled before the expil1~on dale thereof. the j..uing cO~Y.,;1I mail 30 days writlen notice 10 Ihe <br />catificatc holder and additional insureds listed. <br /> <br />~,,7 <br /> <br /> <br />AUT"""""'''''''''''A'''''' ~~ <br />DATE ISSUED: 5/18/04 <br /> <br />