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EVANSTON INSURANCE COMPANY <br />CERTIFICATE NO.: 2017-11 <br />CERTIFICATE OF INSURANCE <br />SPECIAL EVENT LIABILITY PROGRAM <br />1PRODUCER <br />PUBLIC ENTITY (ADDITIONAL INSURED) <br />Altiant 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 Nw OC 36861 <br />NAMED INSURED (EVENT HOLDER): <br />EVENT INFORMATION: <br />Chihiro Sano <br />TYPE: Fitness <br />4365 Johanna Ave <br />DATE(S): 01/01/17 - 12/31/17 <br />Lakewood, CA 90713 <br />LOCATION: Garfield Center /EI Salvador Center/Memorial Park <br />N� <br />4\J - � X(. � U - 0�1 <br />*Liquor Liability YesE] No [] <br />, <br />"Liquor Liability after, 12 am ends before 2 ant El <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 S 2,000,000 <br />Products & Completed Operations 1,000,000 <br />SPECIAL CONDITIONS: <br />Personal & Advertising InJL11-y 1'000'0o0 <br />The following endorsements attached to <br />Each OCCUITencc Limit 1,000,000 <br />the Master Policy do not apply to thus <br />Damage To Premises Rented Tu You (Any Oac Preiffises) 100,000 <br />Certi ficate Of InSfflance: <br />Medical Payments (Any One Person) 5,000 <br />Liquor Liability (if purchased) 1,000,000 <br />Optional Limits Purchased <br />$1,000,0001$3,000,000 <br />"RE <br />. �e'Ved)M" <br />El $2,000,000/$2,000,000 <br />ti <br />Damage To Property (If purchased) <br />C. <br />The limits of insurance apply separately W each event h-ISUred by this policy as if separate policy of insurance has been is o "~ en <br />OTHER ADDITIONAL INSUREDS <br />Alex Warner <br />Berenice Cortez <br />CANCELLATION: Should the above described poky 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 21, 2016 By Stella Fajardo <br />