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BVANSfON RTC <br />URANCECOMPANY <br />CERTIFICATE NO.: 2911 40 <br />CERTIFICATE OFINSURANCE <br />COVERAGE EXCLUDED FOR NOMINEE EVENTS SEE SEPARATE APPLICATIONS FOR NOMINEE EVENTS. <br />SPECIAL EVENT LIABILITY PROGRAM <br />PRODUCER <br />PUBLIC ENTITY (ADDITIONAL INSURED) <br />AllianllnsuranoeSemiCes ,Ino,lncenjundionwilh <br />CYtyofSanleAna <br />Apex Insurance Services <br />20 Civic Center Plan <br />P. 0, Box 6450 <br />Santa Ana, CA 92701 <br />Newport Bad, CA 92658 <br />License No: OC 36961 <br />'HOLDER) <br />TAMED INSURED (EVENT <br />EVENT INFORMATION, <br />Blanca Arceo <br />TYPE', Health & Fitness (sea soort) <br />2022 West Also Ave, <br />DATE(S): 06110111 —I21 M1 <br />Santa Ana, CA 92709 <br />LOCATION' Jerome Center, Southwcat Senior Center <br />'U'quor Liability YesO Nc® <br />"W uorUilit after 12 amends before tam Q <br />This is to certify that the'msurance policy listed kIn has ken issued to the above insured named (evenl holder) for Be policy <br />period indlealed, This oerlillraleis Issued as matter of information only and Confers no MAO upon the unitu ne holder This <br />Certificate does not alTrmalivelyornegatively amend ,ex1¢ndoralterdirco ragea for rd edOyIkepolloy1lstedandhdoesnot <br />constitute aCOntraGbetw¢ enfoe insurance oercler, aulkori2lrepresmtstive ,productr and ceNfuale holder , The'msumnCe <br />desorih ¢dhereinissubjul[oalllhe[ Cans, exbusionsandCOndhiansofsoohpolieyQCS�, <br />INSUAANCEGRRIER, Evanmoo Insurance Company <br />MASTER POLICY NUMBER: I ISEPI000001 <br />MASTER POLICYDATES,EFFECTIYEIANUARY1,2011 EXPIRATION:]ANUARY1,2012 <br />WMM €RCNLGENERALrNBILITY <br />OCCURRENCePORM <br />ryEttUCTIBI,E NONE <br />Gemal Aggr,gal¢Llmil S$aWWO <br />Pr�uLl6 ilCAmPIPIPQ �pd110�9 I,aw,ma <br />Pnsoral &Adv:nisioglojury LOCO,WO <br />tuta�amraumil I,000,000 <br />Pirzryamage(AoyOo¢Fire) SO,gq <br />M¢dioal Paym¢nn(AnyOoePwsoo) f,CW <br />Liquor Liability (IPpnrchase9) Ipao,oW <br />1h¢ Ilmi& ormsmanuppplys�paraRlyb ¢a�¢v¢ol'msured by lhispoliry a9ifattparelepollcy ofimuaoo¢aes 6cea isrvrA forlhal¢uml. <br />"Whoisiosu� "Isamrnd¢dWio¢lude,v sn lnmatl,9ep¢rsonoror�isslioo shox�Innlss�Mul¢, aul only wish aspxl fo 118bllily misiogoul oflhe <br />own¢rship, mainlenmuorus¢o[Ihepl�mis¢suxd 6y lhanam°d io6uro!(¢v¢nlaaWpf 7his'msmmmdocsoolapply la'. Any "o¢wrcom "wM1lsfi laamplam <br />efluAuvml Mld¢ruauslo h¢ale�lmlhalpr¢misa <br />OTHERADDITIONALINSUREDS <br />ANCEtt,AP NI$a041l taBta4i dP6gI�P01Cr aeC9lMS��°afiaeexPl(dl0a d0 @aERar, aalfCWl aLnnlWPd 111 @CLOrd1AfCWItt aEPOlpg <br />PIOVISIOa6 ttVEry EttaI WI nt IApnCrO dP14G7aadySWIIPa awICl�xEceAlaaaEaaaEr9A2E�nload la6Yl�(Sf rlStd. <br />AUTHORIZED REPRESENTATIVE, <br />DATEISSUED: ]une17.201IbvBrinMoml¢s Revlsed1010711IBM <br />