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EVANSTON LNSUR4NCE COMPA?�tY <br />CERTIFICATE NO.: 20I2r05 <br />CERTI FTCATE OF 13V SU RA7VCE <br />SPECIAL EVE1�iT LIA BTLTTV PROGR.A.4T <br />PRODUCER <br />PUBLIC EN TiTY {ADDETfONAL INSURED) <br />AL]iatri Ensurance Services, 3nc_ in conjunction with <br />qty oFSan[a Ana <br />Apez Insurance Services <br />2O Civic Center- Plaaa <br />P_ O. Box 6450 <br />Newport Beach, CA 93658 <br />Santa Ana, CA 42701 <br />License No_ DC 36861 <br />NAMED 3NSUftED (EVENT HOLDER}: <br />EVENT [NFUR[41ATEON: <br />Salomon Rivera <br />TYPE: Dance Narlour] <br />709 S. Parton Slreet <br />DATE(5 )_ O1l031IIl— 12!31172 <br />Santa Ana. CA 92701 <br />LOCATION• t eoi e <br />/�,% <br />7 ^"• � ��?C: t f - i -_�-� <br />`Liquor Liability Yes No <br />+•Li <br />uor [.iabili after ] 2 am ends be {ore 2 am L] <br />This is to certify tha[ the irtsurancc po Eicy ]is[ed below has been issued to the shove insured Warned (event holder) for the polity <br />period indicated. This certificate is issued as a maser of information only and con fans rto rights upon the. certifleaiC hold cr. This <br />txrti Fit:ate does no[ affirm ative]y or negatively amend., extend or alter the covrrage afFox+d ed by the policy listed and it does not <br />constitute a contrd,ct between the insnrantx rani er, authorizrd rep rescntative, producer and txrtifica[e holder_ The insurance <br />described herein is subject m a]E the terms, exclusions and cortd i[ions ofsvch policy(ies)_ <br />7NSU RANCE CARRIER_ Evanston Insurance Company <br />MASTER POLICY NVMBER: 12 SEP7000 DDT <br />MASTER POLICY DATES: EFFECTIVE. JANUARY [, 2012 EXPIRATION: JANL6AftY 1, 3DL3 <br />t- •OA�4MERC1Af_GETiEEtA [. L[AHiLI'fY <br />OCCUREtENCE FOftM <br />E]i1lUC"PBLE' NO[YF. <br />Cr�tteral Aggegsm Limit S?,C3OO.W0 <br />Prodv¢s � Coml,letod Operettnna L,tlf?D,000 <br />/� � }� � (.) �/ {. -� 1) <br />F, � l•� f -` U RM <br />Perxnal 8c Adsrrtising ]njury I,000.00U <br />Each O¢tareace limit 1,00gL1D0 <br />Firs Oarna$e [Arty One Fire) ]00,0!1[1 <br />Tkderal 7 %ysr>Cnis (any One Pvson} S,ODU <br />Ligtror LEabil ity ([i purchased) L•000.000 <br />- -- �tur:a > <br />t[ -S i�crdy <br />OpKonal LlIDl[S Purchased <br />�I 51 ,000,ODO /S3,O00�000 <br />' >.,. >iytaat <br />'i[y �L[orney <br />52,000 OD0/52,000�000 <br />Zits I i[nits of insunue p se In ®eh ovestt insu[ed b ih is pdi�y a it a srparate li of insunutee. has been issuod for [Itat evert[. <br />-wl,o is insured" is atnedtdad to flee! ude, ars an vansred, the pmon or orgnniati,m shown in this sehe>3u le, 1n,C Only with ropes[ [o liability arising out of the <br />wtmtecsisip• fnai[Nenflnx e:r rue of the prQOixs aced by the nanub iasnred (evmt ttolderi- 'LTtis inwsance dos not apyly w: Any "oc urrtsce" which [aloes place <br />aRa the event holder cotses m bees tenant in User pRrnises_ <br />OTHER ADDITT0111AL 1LVSU REDS <br />A A'fION� Shou]d 15te above destsitred policy be. eenex[led 6cfore. Ute nepiruion date thcrenf notice well be deJ ivered in aeoardeaee with the ptrticy <br />xisiont <br />AUTHORIZED REPRESENTATIVE: <br />DATE ISSUED: I J2 V l L by Sriza Morales <br />