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EVANSTON INSURANCE COMPANY <br />CERTIFICATE NO.: 2016-03 <br />CERTIFICATE OF INSURANCE <br />SPECIAL EVENTLIABILITY PROGRAM <br />PRODUCER <br />PUBLIC INT'ITY (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 />Terry Subandhi °} . �cM( t "�� ."°�`) <br />TYPE: Badminton <br />14862 Coletta Plaice <br />DATE(S): 01/0I/16—'12/31/16 <br />Westminster, CA 92683 <br />LOCATION: Salgado Center <br />*Liquor- Liability Yes [] No E <br />"Liquor.Liability after 12 am ends before 2 am ❑ <br />"[`his 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: SEP41020 <br />MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2016 EXPIRATION: JANUARY I, 2017 <br />COMMERCIAL. GENERAL. IAA[3flJTY <br />OCCURRENCE FORM <br />DEDUCTIBLE: NONE <br />General Aggregate Limit $ 2,000,000 <br />Products & Cotnplete�d Operations I,00Q,00o <br />SPECIAL,CONIa r[ONS: <br />Personal & Advertising Injury 1,000,000 <br />Each Oa:eurrence 1 imit I,000,mo <br />The folVendorsements attached to <br />tic M&i do <br />cQgjH cy coot apply to this <br />Damage'I'o Prernises Rented To You (Any One Premises) IW000 <br />to Ot Insorancc <br />Medical Payments (Any One Person) 5,000 <br />Liquor Liability (if purchased) 1,000,000 <br />d y jsf <br />y� <br />e <br />Optional Limits Purchased <br />0 $1,000,000/$3,000,000 <br />[] S2,000,000/$2,000,000 <br />Damage To <br />Properly (If purchased) <br />The limits of insurance apply separately to each event insured by this policy as if a separate policy of insrrance has been issued for that event_ <br />OTHER ADDITIONAL INSUREDS <br />CANC E[..I..A"PION: Shnuld the above described policy be cancelled before the expiration date thereof; nonce will be delivered in accordance with the policy <br />provisions. <br />AUTHORIZED REPRESENTATIVE: <br />DATE ISSUED: December- 15 2015.by Briza Morales <br />