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EVANSTON INSURANCE COMPANY <br />CERTIFICATE NO.: 2016-08 <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 Ann, CA 92701 <br />Newport Beach, CA 92658 <br />License No: OC 36861 <br />NAMED INSURED (EVENT HOLDER): <br />EVENT INFORMATION: <br />Khai (Kevin) Iloang 1� - 1 S'�- 1Q0 <br />TYPE: Dance/Fitness <br />14401 Poplar <br />DATE(S): 01l01/16- 12/31/16 <br />Tustin, CA 92780 <br />LOCATION: Southwest Senior Center/Garfield Center <br />*Liquor Liability Yes ❑ No <br />"Liquor Liability after 12 am ends before 2 ant ❑ <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: SEP41020 <br />MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2016 EXPIRATION: JANUARY 1, 2017 <br />COMMERCIAL GENERAL LIABILITY <br />OCCURRENCE FORM <br />DEDUCTIBLE; NONE <br />General Aggregate Limit $ 2,000,000 <br />Products & Completed Operations I,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'ro Premises Rented To You (Any One Premises) 100,000 <br />Certificate Ofhtsurcum <br />Medical Payments (Any One Person) 5,000 <br />Liquor Liability (If purchased) 1,000,000 <br />Optional Limits Purchased <br />❑ $1,000,000/$3,000,000 <br />6`I�eVJ <br />❑ $2,000,000/$2,000,000 <br />t <br />Damage To Property (If purchased) <br />. <br />uQva>,r <br />`rhe limits of insurance apply separately to each event insured by this policy as if separate polic msurim <br />t for 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 />revisions. <br />AUTHORIZED REPRESENTATIVE: <br />DATE ISSUED: December 16 2015 by Briza Morales <br />