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EVANSTON INSURANCE COMPANY <br />CERTIFICATE NO.: 2016-13 <br />CERTIFICATE OF INSURANCE <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 />Theresa Robertson 2 <br />'TYPE: Dance <br />16889 Nichols Street #D <br />DATE(S): 01/01/16 - 12/31/16 <br />Huntington Beach, CA 92647 <br />LOCATION: Southwest Senior Center <br />*Liquor Liability Yes [:1 No M <br />"Liquor Liability after 12 am ends before 2 am L1 <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. The insurance described herein is Subject to all the terms, exclusions and conditions of such policy(ics) unless <br />amended as described in Special Conditions. <br />INSURANCE CARRIER: Evanston Insurance Company <br />MASTER POLICY NUMBER: SEP41020 <br />NIASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2016 EXPIRATION: JANUARY 1,2017 <br />COMMERCIAL GENERAL LIABILITY <br />OCCURRENCE FORM <br />DEDUCTIBLE: NONE <br />Genera9 Aggegate 1-finit S2,000,000 <br />Products & Completed Operations 1,000,000 <br />SPECIAL CONDITIONS: <br />Personal & Advertising Injury I i000,000 <br />The following endorsements attached to <br />Each Occurrence Limit 1,000,000 <br />the Master Policy do not apply to this <br />Darnage'T"o Premises Rented TO YOU (Any One PTCMISCS) 100,000 <br />CeftlfiCate Of Insurance:: <br />Medical Payments (Any One Person) 5,000 <br />Liquor Liability (If purchased) 1,000,000 <br />Optional Limits Purchased <br />El 51,000,00053,000,000 <br />F-1 $2,000,000/$2,000,000 <br />Damage To Property (If purchased) <br />�p�WN <br />The I irfl its Of insurance apply separately to each event insured by this policy as i f a separate policy Of insurance has bvei!T�issued for that event. <br />OTHER ADDITIONAL INSUREDS <br />CANCELLATIW Should the above described policy be cancelled before the expiration date thereoC, notice will be delivered in accordance with the policy <br />provisions. <br />AUTI-IORIZED REPRESENTATIVE: <br />DATE ISSUED: — December 29, 2015 by Briza Morales <br />