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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 LIABIUTY PROGRAM <br /> <br />PRODUCER: <br /> <br />f'.i; ~2.000-~T <br />. ;v- w3-~5 <br />Driver Allilljlt Insurance Services~ - 2tX>1- - II L( <br />P.O.Box28323 -~-ctf <br />Santa Ana, CA 92799.8323 . <br />(949) 660-8163 I J 'oCV[) - ill <br />License No: OC 36861 JV <br />NAMED INSURED (EVENT HOIDER): <br />I <br />ToYlY Velga.do <br /> <br />PUBUC ENTITY (ADDmONAL INSURED) <br /> <br />c.uy 06 Sa.n.ta. Ana. <br />ZO C~v~e Cente4 Plaza., M-28 <br />Sa.n.ta. Ana., CA 9Z701 <br /> <br />EVENTlNFORMATION: . ..A.' S.'6 <br />TYPE: IMtJw.c.:tio"'M..- <--<- <br />DATE(S): I/Ub/U~ - IZPI/U' <br />LOCATION: S.A. JGU..{. <br /> <br />ImpJr.ovemeYlt <br /> <br />This is to certify that the policies of insurance listed below have been issued to the insured uamed above for the policy period <br />indicated. NotwitbataudiDg my requiremeub, terms or CODditioIIs of any conlIact or other document with respect to which this <br />certificate. may be issued<< may pertaiD, the insurance afforded by the policies descnbed herein is subject to all the tenDs, <br />exclusions and conditions of such policies. Limits shown may have been reduced by paid claims. <br />INSURANCE CARRIER: EVlIIISloD InsUIal1Ce Company <br /> <br />MASTER POLICY NUMBER: OSSEPlOOOOOI <br /> <br />MASTER POLICY DATES: EFFECTIVE: JANUARY 1,2005 EXPIRATION: JANUARY I, 2006 <br /> <br />COMMERCIAL GENERAL UABILITY <br />GencnlI AaPe.... limit <br />ProdUCII a: ~ Opcntioa. <br />PenonaI a: AdYatisina: Iojury <br />Each Oc:cunmc:o Umit <br />Fire ilImIBc (Any One Fire) <br />Medi<al Payments (Any One Pr:non) <br /> <br />S 2.000.000 <br />1.000.000 <br />1.000,000 <br />1,000.000 <br />50,000 <br />5.000 <br /> <br />OCCURRENcE FOIlM <br /> <br />DEDUCTmLE: NONE <br /> <br />The limib of ilwnnc:c _Iy '0ll1l'l..1y to each CYalt _ by "'i. policy u if. -'" poIiey of i_ hu been iuued fOR !HAT ""..L <br />"WOO is inaured" i. amended to inelude, .. an illl1llOd,tho _ or OI'plllzalioo shown In IbillCbodule, but only wilb _ to liabfHty aims out of tho <br />owncnhip. maintenance or u.. of the .......... - by 1bc named insured (...... holder). Thi. inaurance d.,.. not """Iy 10: Any "occum:tlCC" ","ch taItcs place <br />aft:crthc: nent holderceues tD'be a term1t in IhIt <br /> <br />OTHER ADDrnONAL INSUREDS <br /> <br />CANCF.IJ.A TION: Should 1bc ahoYc deaenbcd policy 10 canodled l>efon: tho expiration dall: Il1...oJ; 1bc i..uing c~y will mail 30 doys written llOiiee 10 tho <br /><<<tifieall: holder and additional inM<>cb lilted. <br /> <br />AurnoRIZED REPRESENTATIVE: <br /> <br />~;z' ~ <br /> <br />DATE ISSUED: <br /> <br />Ja.YlUiVLY 6, Z005 <br /> <br />.' :.,;)\:iL:C;' j\,__ ~,\ ,U\I <br /> <br /> <br />,;,~~(1Iy <br />~-.,\..- <br />