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EVANs,rON INSURANCE COMPANY <br />CERTIFICATE NO.: 201E-04 <br />CERTIFICATE OF' INSURANCE <br />SPECIAL EVENT LIABILITY PROGRAM <br />PRODUCER I PUBLIC ENTITY (ADDITIONAL INSURED,) tin <br />Alliant Insurance Services„ Inc. in conjunction with City of Santa Ana <br />Apex Insurance Services 20 Civic Center Plaza <br />P. O. Box 6450 Santa Ana, CA 92701 <br />Newport Reach, C.A 92658 <br />License No: OC 36861 <br />NAMED INSURED (EVENT HOLIER): <br />EVF]" T INFORMATION: <br />Kevin Dalrymple ("'ww"b c 1...�"� �:�.. (�y � � <br />TYPO: Judo <br />5547 :San Juan Drive <br />DATE(S): 01/01/16—12/31/16 <br />Orange, CA 92869 <br />LOCATION: Southwest Senior Center <br />*Liquor Liability Yes ❑ No 0 <br />**Liquor Liability after 12 ann ends before 2 aun ❑ <br />']'his is to certify that the insurance policy listed below has been issued to the above insured nailed (event holder) for the policy <br />period indicated. The insurance described herein is subject to all the terms, exclusions and conditions of such policy(ies) unless <br />amended as described in Special Conditions. <br />INSURANCE CARRIER: Evanston Insurance Company <br />MASTER POLICY NUMBER: SEP41020 <br />MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2016 EXPIRATION: JANUARY 1, 2017 <br />COMMERCIAL G ENI:RAL LIABILITY <br />OCCURRENCE FORM <br />DFI UC'TIBLE ➢V(3N <br />Creneial Aggregate Limit 2,000,000 <br />Products & Completed Operations 1,000,000 <br />SPECIAL CONDITIONS: <br />Personal &, Advertising htjury 1,000,000 <br />The following endorseincnls attached to <br />Fach Occurrence Limit 1,000,000 <br />the Master Policy do not apply to this <br />Damage Ill Premises Rented To YOU (Any One Premises) 100,000 <br />Certificate Cif' Pnsrnance: <br />Medical Payments (Any One Person) 5,000 <br />Liquor Liability (If purchased) l'000 Ot70 <br />Optional Limits Purchased <br />W J <br />❑ $1,000,00053,000,000 <br />❑ $2,000,00052,000,000 <br />Damage To Property (If purchased) <br />V <br />'rhe ( units oP insurance apply separately to each eVeart insured by thus policy as il'a separate pol icy �' GranGe t " e rr that event. <br />OTHER ADDITIONAL INSUREDS <br />C;;ANCGL.I..A NON: Should the above; described policy be cancelled belbre the expiration date thereof, notice will be delivered in accordance with the policy <br />arovisicros. <br />AUTHORIZED REPRESENTATIVE: <br />DATE ISSUED: December 1.5 2015 b Briza Morales <br />