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EVANSTON INSURANCE COMPANY <br />CERTIFICATE NO.: 2017-09 <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 />Santiago Bautista <br />TYPE: Martial Arts <br />1523 W Sixth. Street <br />DATE(S): 01/01/17 — 12/31/17 <br />Santa Ana, CA 92703 <br />LOCATION: Memorial, El Salvador, & Salgado Center <br />*Liquor Liability Ycs 0 No <br />�. �0ti <br />'t'� <br />**Liquor LiabilitX 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. 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: SEP41023 <br />MASTER POLICY DATES: EFFECTIVE: JANUARY I, 2017 EXPIRATION: JANUARY 1, 2018 <br />COMMERCIAL GENERAL LIABILITY <br />OCCURRENCE FORM <br />L EIDUC; r1131.,F, NONE <br />General Aggregate Limit $ 2,000,000 <br />Products & Completed Operations 1,000„000 <br />SPECIAL. CONDITIONS: <br />Personal & Advertising Injury 1,000,O00 <br />The following endorsements attached to <br />Each Occurrence Limit 1,000,000 <br />the. Master Policy do not apply to this <br />Damage To Premises Rented'ro You (Any One Premises) 100,000 <br />Certificate Of Insurance: <br />Medical Payments (Any One Person) 5,000 <br />Liquor Liability (If purchased) 1,000,000 <br />Optional Limits Purchased <br />© $1,000,00053,000,000 <br />❑ $2,000,000/$2,000,000 <br />Damage To Property (If purchased) <br />l`h,e limits of insurance apply separately to each event insured by this policy as if separate policy of insurance has been issued for that event. <br />OTHER ADDITIONAL INSUREDS <br />Justin Unswvorth. <br />Pete Mangosing <br />Jesus Bautista <br />Mario Rivera <br />Jose Lopez <br />Clelia Mouser <br />CANCELLATION: Should the above described policy be cancelled before the expiration date thereof„ notice will be delivered in accordance with the pokey <br />provisions. <br />AUTHORIZED REPRESENTATIVE: <br />DATE ISSUED: <br />V. <br />V <br />