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EVANSTON NSURANCE COMPANY <br />CERTIPICATENO,: 2= <br />CERTIFICATE OF INSURANCE <br />SPECIAL EVENT LIABILITY PROGRAM <br />PRODUCER PUBLIC ENTITY (ADDITIONAL INSURED) <br />Alli and InsumnceSen iciInc. meunjunelionWthCity <br />1ofSanta Ana <br />Apex lasuranceSemies <br />20 Cil Center Plaza <br />P.O. Bax 6430 <br />Newpadeearh,CA926H <br />Santa Ana, CA 92701 <br />License No: OC 36861 <br />NAMED INSURED (EVENT HOLDER): <br />EVENT INFORMATION, <br />Patrick Hurley <br />TYPE Your <br />14910 Mhowh Court <br />DATE(S) 01104112-12131112 <br />Tall W80 <br />LOCATION, III Sdval Center <br />,��� _��� ��� <br />"Liquor Cmbility Ye l] No® <br />"Livor Liabili a0erl2emeodsbefom2am0 <br />This is to cis $9 theimurance policy It below has I= issued to Jt above insured named (event holder) for the policy <br />period indicated, TM1Is mnifinele Ishsutdas a metier afinfonnmion only and canferr no rights upon the uA'tEoare lodm. This <br />cenifcere does notafffrmaobelyornegalively amurd, extend or alterthc coverage afforded by the panty listed and IARs not <br />o0 irate arcntmct between Ae'mswanrc carier, amhorized represenmlive,producer and certlfcareholder The inciini <br />desc{3ed heminlssubjrctfo ell0e leans, exclusions and conditions of such pollcy(es), <br />INSURANCE CARRIER, Evarhoo Insurance Company <br />MASTER POLICY NUMBER. 12SEPI000DOI <br />MASTER POLICY DATES: EFFECTIVE: IANUARY I, 2012 EXPIRATION: JANUARY], 2013 <br />COMMECIALCENERALLIVBILUY <br />CCCIIPEENCE FORM <br />DFDUCImLR. NOW <br />Cmml AgintudsWmil s$oW,W4 <br />Holum@Cmplk 6yenpms I,mm <br />PemondiAdrolivgii IXcii <br />fuhAm=eLimit I,Xaw <br />FreDrop(Ar imFml IWWO <br />Round lnm=(Any ON Pend S,WO <br />Liquor Lei (If purchased) yoagWE <br />Optional Limits Purchased <br />0 s1,Boo,�oP2,Noo,oBo <br />D S1,000,WOIS2,ODD 0(b <br />TFel ¢oftivrei i sg2malytoesvhevenl imwol6yrha norty1i <br />"WhoEvvod"isunwddla nduk umi urtd, Ihopmon mtvgmWlionahown to Ws xhrdul4WloolywhrisNvl wliahillrynndirl moAhe <br />ownmhip,mvnmeormofihep%mittsus�hythenamod imumd(evmlkldn) Thuinnumeedrvsoaapplym'. Aoy"ueunase"uLohukesp'vq <br />Wirttlkevm �OderoafetWlkalmmtl inAalpmnirte <br />OTHER ADDITIONAL INSUREDS <br />UENLlId11CN" mouldJw¢horedouriMd{aliry6eren<'vlls-0hefinetreaapvalioodm<thpro[nooasnlllwddivmdln�mdmvewlAWpoliq <br />onsiom. <br />AUTHORIZED REPRESENTATIVE: <br />DATE ISSUED, 09111 by Briza Morales <br />