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E v ANSTON INSURANCE COMPANY CERTIFICATE NO.: 2009-01 CERTIFICATE OF INSURANCE EXCLUDES COVERAGE FOR NOMINEE EVENTS. SEE SEPARATE APPLICATIONS FOR NOMINEE EVENTS. SPECIAL EVENT LIABILITY PROGRAM PFtODI TCER: PUBLIC ENTITY (ADDITIONAL INSURED) City of Santa Ana A. Iiant Insurance Services, Inc. in conjunction with 20 Civic Center Plaza Apex Insurance Services Santa Ana, CA 92701 I' O. Box 6450 Nhtwport Beach, CA 92658 (949)660-8135 _License No: OC 36861 NAMED INSURED (EVENT HOLDER): EVENT INFORMATION: Salomon Rivera TYPE: Dance - Salsa 709 S. Parton Street DATE(S): Jan. 5 - Dec. 31 Santa Ana, CA 92701 _ LOCATION: Southwest Senior Center *Liquor Liability Yes ❑ No — --- **Li uor Liabilit after 12 am ends before 2 am ❑ 7 •ius is to certify that the policies of insurance listed below have been issued to the insured named above for the policy period nlicated. Notwithstanding any requirements, terms or conditions of any contract or other document with respect to which this certificate may be issued or may pertain, the insurance afforded by the policies described herein is subject to all the terms, exclusions and conditions of such policies. Limits shown may have been reduced by paid claims. INSURANCE CARRIER: Evanston Insurance Company MASTER POLICY NUMBER: 04SEP1000001-5 MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2009 EXPIRATION: JANUARY 1, 2010 ( � fMMERCIAL GENERAL LIARILfTY Otneral Aggregate Limit OCCURRENCE FORM DEDUCTIBLE: NONE $ 2,000,000 Products & Completed Operations 1,000,000 Personal & Advertising Injury 1,000,000 Each Occurrence Limit 1,000,000 Fire Damage (Any One Fire) 50,000 Nl-dical Payments (Any One Person) 5,000 Liquor Liability (If purchased) 1,000,000 I I e 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. "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 nvmership, maintenance or use of the premises used by the named insured (event holder). This insurance does not apply to: Any "occurrence" which takes place aver the event holder ceases to be a tenant in that premises. OTHER ADDITIONAL INSUREDS C \NCELLATION, Should the above described policy to cancelled before the expiration date thereof, the issuing company will mail 30 days written notice to the certificate holder and additional insureds listed. I7'CHORIZED REPRESENTATIVE: A,rF ISSUED: / / 5 /O