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EVANSTON INSURANCE COMPANY <br />CERTIFICATE NO.: 2017-23 <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 />Martin Torres <br />TYPE: Martial Arts <br />12692 Ranchero Way <br />DATE(S): 1/09117-12/31117 <br />Garden Grove, CA 92843 <br />LOCATION: Jerome Center <br />*Liquor Liability Yes ❑ No <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. 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: SEP41023 <br />MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2017 EXPIRATION: JANUARY 1, 2018 <br />COMMERCIAL GENERAL LIABILITY <br />OCCURRENCE FORM <br />DEDUCTIBLE: NONE <br />General Aggregate Limit $ 2,000,000 <br />Products & Completed Operations 1,000,000 <br />SPECIAL CONDITIONS: <br />Personal & Advertising Injury 1,000,000 <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 To 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 />arpy'. <br />� <br />❑ $1,000,000/$3,000,000 <br />$2,000,000/$2,000,000 <br />El6 <br />Rev`/ <br />Damage To Property (If purchased) <br />G%poa <br />s`�vta Pd <br />��• <br />The limits of insurance apply separately to each event insured by this policy as if a separate policy aqhW. has been issued for that event. <br />OTHER ADDITIONAL INSUREDS <br />Itzel Barrios <br />CAN Should the above described policy be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy <br />rovisums. <br />AUTHORIZED REPRESENTATIVE: <br />DATE ISSUED: January 9. 2017 by Stella Fajardo <br />