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EVANSTON INSURANCE COMPANY <br />CERTIFICATE NO.: 2017-16 <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 1lOLDER): <br />EVENT INFORMATION: <br />Khai (Kevin) Hoang <br />TYPE: Fitness <br />14404 Poplar <br />DATE(S): 01/01/17—12/31/17 <br />Tustin, CA 912780 <br />LOCATION: Southwest Sr. Center/Jerome Center <br />� � ( <br />*Liquor Liability Yes ❑ No Z <br />"Liquor Liability 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. 'rhe 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: SEP41023 <br />MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2017 EXPIRATION: JANUARY 1, 2018 <br />COMMERCIAL GENERAL LIABILITY OCCURRENCE FORM & FDUCTIBLE.; NONE' <br />General Aggregate Limit $ 2,000,000 <br />Products & Completed Operations 1,000,000 SPECIAL CONDITIONS: <br />Personal & Advertising Injury 1,000,000 The following endorsements attached to <br />Each Ciccnrrence L.intit 1,000,000 the Cvlaster Policy do not apply to this <br />Damage To Premises Eentcd To You (Any One Premises) 100,000 Certificate Of Insurance: <br />Medical Payments (Any One Person) 5,000 <br />Liquor Liability (If purchased) I,00o,000 ° <br />Optional Limits Purchased ' <br />❑ $1,000,000/9,000,000 <br />❑ $2,000,000/$2,000,000 <br />Damage To Property (If purchased) , <br />The limits of insurance apply separately to each event insured by this policy as if a separate policy of insurance has beers od''for that event. <br />OTHER ADDITIONAL. INSUREDS <br />C'ANC.ELLA PION: Should the above described policy be cancelled before the expiration date thereof, notice Will be delivered in accordance With the policy <br />provisions. <br />AUTHORIZED REPRESENTATIVE: <br />DATE ISSUED: December 28 2016b Stclla Fajardo <br />