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EVANSTON INSURANCE COMPANY <br />CERTIFICATE NO.. 2011 -13 <br />CERTIFICATE OF INSURANCE <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 />Alliant Insurance Services, Inc. in conjunction with <br />City of Santa Ana <br />Apex Insurance Services <br />20 Civic Center Plaza <br />P. O. Box 6450 <br />Santa Ana, CA 92701 <br />Newport Beach, CA 92658 <br />License No: OC 36861 <br />NAMED INSURED (EVENT HOLDER): <br />EVENT INFORMATION: <br />Rudy Sehuame <br />TYPE: Martial Arts <br />2424 West 1 ", #133 <br />DATE(S): 02/02/11 - 12/31/11 <br />Santa Ana, CA 92703 <br />LOCATION: Santa Anita Recreation <br />N- 2006 -029 -06 <br />*Liquor Liability Yes � No <br />- <br />* *Li uor Liabili after 12 am ends before 2 am � <br />This is to certify that the insurance policy listed below has been issued to the above insured named (event holder) for the policy <br />period indicated. This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This <br />certificate does not affirmatively or negatively amend, extend or alter the coverage afforded by the policy listed and it does not <br />constitute a contract between the insurance carrier, authorized representative, producer and certificate holder. The insurance <br />described herein is subject to all the terms, exclusions and conditions of such policy(ies). <br />INSURANCE CARRIER: Evanston Insurance Company <br />MASTER POLICY NUMBER: 11SEP1000001 <br />MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2011 EXPIRATION: JANUARY 1, 2012 <br />COMMERCIAL GENERAL LIABILI'T'Y <br />OCCURRENCE FORM <br />DEDUCTIBLE: NONE <br />General Aggregate Limit - $ 2,000,000 <br />Products 8c Completed Operations 1,000,000 <br />Personal 8c Advertising Injury 1,000,000 <br />Each Occurrence Limit 1,000,000 <br />Fire Damage (Any One Fire) 50,000 <br />Medical Payments (Any One Person) 5,000 <br />Liquor Liability (If purchased) 1,000,000 <br />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. <br />"Who is insured" is amended to include, as an insured, the person or organia[ion shown in this schedule, but only with respect [o liability arising out of the <br />ownership, maintenance or use of the premises used by [he named insured (event holder). This insurance does not apply to: Any "occurrence" which Takes place <br />after the event holder ceases to be a tenant in that premises. <br />OTHER ADDITIONAL INSUREDS <br />CAN ATION� Should the above described policy be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy <br />rovisioru. Ev effort will be made to deliver 30 da s written notice to the certificate holder and additional insureds listed. <br />AUTHORIZED REPRESENTATIVE: � � c�J�^�! a )'t� { <br />DATE ISSUED: February 02. 2011 by Briza Morales - " ---� ` - "��2 <br />� —��a SCltt Sli <br />%assistant City A <br />