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EVANSTONINSURANCECOMPANY <br />CERTIFICATE NO.: 2017-22 <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, 0. 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 <br />TYPE: Dance <br />16889 Nichols Street #D <br />DATE(S): 01/09/17 —12/31/17 <br />Huntington Beach, CA 92647 <br />LOCATION: Southwest Senior Center <br />I _�� 1 <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 />DEDUCIBLE. NONE <br />General Aggregate Limit S2.000,000 <br />Products & Completed Operations 1,000,000 <br />SPECIAL CONDITIONS: <br />Personal & Advertising Injury 1,000,000 <br />'fire 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 />0 <br />❑ $1,000,000/$3,000,000 <br />YI, <br />❑ $2,000,000/$2,000,000 <br />Damage To Property (If purchased) <br />ff}s S = <br />The limits of insurance apply separately to each event insured by this policy as its separate policy of insurance hes b�Rqssuad far that event. <br />OTHER ADDITIONAL INSUREDS <br />CANCELLATION: Should the above described policy be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy <br />provisions. <br />`..Jz,.. <br />AUTHORIZED REPRESENTATIVE: <br />DATE ISSUED: January 5 2017 by Stella Faiardo <br />