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N- 2005 - 101 -04 EVANSTON INSURANCE COMPANY CERTIFICATE NO.: 2009 -31 CERTIFICATE OF INSURANCE EXCLUDES COVERAGE FOR NOMINEE EVENTS. SEE SEPARATE APPLICATIONS FOR NOMINEE EVENTS, SPECIAL EVENT LIABILITY PROGRAM PRODUCER: PUBLIC ENTITY (ADDITIONAL INSURED) City of Santa Ana Alliant Insurance Services, Inc. in conjunction with 20 Civic Center Plaza Apex Insurance Services Santa Ana, CA 92701 P. O. Box 6450 Newport Beach, CA 92658 (949) 660 -8135 License No: OC 36861 NAMED INSURED (EVENT HOLDER): EVENT INFORMATION: Raymundo Suarez TYPE: Martial Arts 610 S. Townsend Street DAT$(S): September 1.2009 - December 31, 2009 Santa Ana, CA 92703 LOCATION: El Salvador Recreation Center *Liquor Liability Yes ❑ No "Liquor Liabili after 12 amends before 2 am ❑ This is to certify that the policies of insurance listed below have been issued to the insured named above for the policy period indicated. Notwithstanding any requirements, terns or conditions of any contract oi• 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: 04SEP100000I -5 MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2009 EXPIRATION: JANUARY i, 2010 COMMERCIAL GENERAL LIABILITY OCCURRENCE FORM DEDUCTIBLE: NONE General Aggregate Limit $ 2,000,000 Products & Completed Operations 11000,000 Personal & Advertising Injury 1,000,000 Each OccutrcnccLimit 1,000,000 Fire Damage (Any One Fire) 50,000 Medical Payments (Any Ono Person) 5,000 Liquor Liability (If purchased) 1,000,000 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. "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 outof the ownership, maintenance or use of the premises used by the named insured (event holder). This insurance does not apply to: Any "occurrence" which takes place after the event holder ceases to be a tenant in that premises. OTHER ADDITIONAL INSUREDS o ILIA A,P13 � - t Sheed Y a - /Lau rn,y Assistant. CANCELLATION: 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. AUTHORIZED REPRESENTATIVE: DATE ISSUED: — _ September 1. 2009 4