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N- 207 7 -134 <br />EVANSTON INSURANCE COMPANY <br />CERTIFICATE NO.. 2011 -12 <br />CERTIFICATE OF INSURANCE__,,. A�.t �]� `�I t �t <br />COVERAGE EXCLUDED FOR NOMINEE EVENTS SEE SEPARATE AP]?ii1� #'1�10�!'ti FOR PVIU1Vi�IEE EVENTS. <br />SPECIAL EVENT LIABILITY PROGRAM <br />•r <br />PRODUCER <br />PUBLIC ENTIT?�` (riDDITIQNEII{��iy�'+LfR!(�D) <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 />Salomon Rivera <br />TYPE: Dance <br />709 S. Parton Street <br />DATE(S): 0126/11 — 12!31!11 <br />Santa Ana- CA 92701 <br />LOCATION: Southwest Senior Center <br />- <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 LIABILITY <br />OCCURRENCE FORM <br />DEDUCTIBLE: NONE <br />Grneral Aggregate Limic $ 2,000,000 <br />Products � Completed Operations 1,000,000 <br />Personal � Advertising Injury 1,000,000 <br />Each Occurrence Limi[ 1,000,000 <br />Fire Damagc (Any One Fire) 50,000 <br />Medical Payments (Any One Person) 5,000 <br />Liquor Liability (if purchased) 1.000,000 <br />Thc limits of insurance apply separately to each event insured by This policy es i£ 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 organization shown in this schedule, but only with respect to IiabiliTy arising out oft}te <br />ownership, maintenance or use of the premises used by [he named insured (event holder). This insurance does not apply [o: Any "occurrence" which takes place <br />after the evrn[ holder ceases to be a trnant in that premises. <br />OTHER ADDITIONAL INSUREDS <br />CANCELLATION Should the above described policy be cancelled before the expiration dale thereof, notice will be delivered in accordance with the policy <br />rovisions. Ev effort will be made to deliver 30 da s written notice to the certificate holder and additional insureds listed. <br />AUTHORIZED REPRESENTATIVE: �� <br />DATE ISSUED: January 26, 2011 by Briza Morales ^- F'YT��� V j - =g> A4 'I�<J ¢�C�izNf <br />LaurtJ / %'�i Sl���;cdy <br />Assistant City All c�nic;� <br />