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86698-4-P MATCH 00534 MUTL VOL <br />StdeFwmState Farm Mutual Automobile Insurance Company <br />PO Box 853922 <br />Richardson, TX 75085-3922 <br />00534 <br />NAMED INSURED 75.7501.4 P A <br />000s3s oose <br />NANCY K BOHL INC <br />DBA THE COUNSELING TEAM <br />INTERNATIONAL <br />PO BOX 10427 <br />SN BERNRDNO CA 92423-0427 <br />DECLARATIONS PAGE I <br />PAGE 2 OF 2 <br />POLICY NUMBER 441 4187-F24-75W <br />POLICY PERIOD OCT 31 2019 to JUN 24 2020 <br />12:01 A.M. Standard Time <br />EXCEPTIONS, POLICY BOOKLET & ENDORSEMENTS (See policy booklet & individual endorsements for coverage details.) <br />FORM POLICY AND ANYSENDORSEMENTSLTHATIAPPLY, IACLUDINGLTHOSE0IISSUED TO YOU <br />WITH ANY SOBSEIUENT RENEWAL NOTICE. <br />01 6029SU ADDI IONAL INSURED -THE ORGANIZATIONAL NETWORK, PO BOX 10427, SN <br />BERNRDNO CA 92423-0427. <br />02 6028BU ADDITIONAL INSURED -CITY OF REDLANDS ATTN: RISH M ANAGEMENT, PO <br />033X602886 ADDITIONALAINSURED-CITY OF GARDEN GROVE ITS OFFICERS OFFICALS <br />AGTS EMPL AND VOLUNTEERS ATTN RISK MNGT, 11222 ACACIA PKWY, GARDEN GROVE CA <br />92840-5208. <br />04 6028BU ADDITIONAL INSURED -RIVERSIDE CITY POLICE, 4102 ORANGE ST, <br />RIVERSIDE CA 92501-3671. <br />05 6028BU ADDITIONAL INSURED -CITY OF GLENDALE AND ITS OFFICERS AGENTS <br />5P6028BU ADDITIONALEINSURED-NE3CITYIOFBMORENO VALLEYLISAOA91PD6BOX188005, <br />M©RENO VALLEY CA 92552-0805. <br />07 6028BU ADDITIONAL INSURED-SAN MANUEL BAND OF MISSION INDIANS AND ITS <br />AFFILIATES ENTITIES INSURANCE COMPLIANCE PO BOX 100085-M9 DULUTH GA 30096. <br />08 6028BU ADDITIONAL INSURED -COUNTY OF RIVERSIDE ISAOA, 29$0 WASHINGTON ST, <br />RIVERSIDE CA 92504-4647. <br />09 6028BU ADDITIONAL INSURED -ORANGE COUNTY FIRE AUTHORITY ISAOA, 1 FIRE <br />AUTHORITY RO IRVINE CA 92602-0125. <br />OFFFICERSU AGENTSON&EMPLOYEES,T211CST1SOFSTLHAMBAM$RA CAT91801-3706. <br />11 6028BO ADDITIONAL INSURED-SAN BERNARDINO CITY UNIFIED SCHOOL DISTRICT, <br />ITS TRUSTEES,, OFFICERS, EMPLOYEES AND AGENTS777 N F STREET, SN BERNRDNO CA <br />92410. <br />12 6028BU ADDITIONAL INSURED -CITY OF RIVERSIDE IT'S OFFICERS & EMPLOYEES, <br />13060 8BU AMITIONALIINSURED�COUNTY0OF ORANGE ISAOA, 1055 N MAIN ST, SANTA <br />ANA CA 92701-3601. <br />14 6028BU ADDITIONAL INSURED -WEST BASIN MUNICIPAL WATER DISTRICT ISAOA, <br />17140 AVALON BLVD STE 210 CARSON CA 90746-1242. <br />15 6028BU ADDITIONAL INSURED -THE COUNTY DISTRICTS OF SAN BERNARDINO, ISAOA <br />ATTN: EBIX PO BOX 257 PORTLAND MI 48875-0257. <br />16 6028BU ADDITIONAL INSURED -CITY OF CORONADO, 101 B AVE, CORONADO CA <br />92118-1510. <br />17 6028BU ADDITIONAL INSURED -CITY OF HUNTINGTON BEACH IT'S OFFICER'S, ISAOA, <br />200 MAIN ST HUNTINGTN BCH CA 92648-8121. <br />18 6028BU ADDITIONAL INSURED -CAL STATE POLYTECHNIC UNIV, POMONA, 3801 W <br />19M6028BUEADDPIOTIONNALAINSURED-CITY OF SAN BERNARDINO IT'S OFFICERS', ISAOA <br />ATTN: HUMAN RESOURCES 290 N D ST SN BERNRDNO CA 92401-1734. <br />206028BU ADDITIONAL SPGSDCAE92240HOT SPRINGS POLICE DEPARTMENT, 65900 <br />PIERSON 21 6028BU ADDITIONAL INSURED -CITY OF EL SEGUNDO OFFICERS, OFFICIALS, <br />22P60028BUAADDITIONALOINSURED-CITYSAP CARSONUAND ISAOA24ATTENTION PURCHASING <br />DIVISION 701 E CARSON ST, CARSON CA 90745-2257. <br />COMPLLIANCEASSERVICCESLPONBOX 4668UINTW YORKENYU10I63-4668IGIS INSUR <br />24 6028BU ADDITIONAL INSURED -CITY OF SANTA ANA, ISAOA, 20 CIVIC CENTER PLZ <br />25 5 2ABUAADDITIONAL INSURED -THE CITY OF ONTARIO, 303 E B ST, ONTARIO CA <br />91764-4196. <br />6028BU ADDITIONAL INSURED. <br />6196AA WAIVER OF SUBROGATION UNDER THE LIABILITY COVERAGE. <br />603OGF BUSINESS NAMED INSURED. <br />6126MO EXCESS COVERAGE FOR PERSONAL VEHICLE SHARING. <br />612BAC AMENDATORY ENDORSEMENT. <br />[6[049CB USE OF NON -OWNED CARS- LIABILITY AND MEDICAL PAYMENTS COVERAGES <br />6©333BL USSEMO� NON-OWNEDOCARS-COMPREHENSIVE COVERAGE AND COLLISION <br />COVERAGE; NANCY K BOHL 30 000 LIMIT. <br />6196AA WAIvv R N SUBROGATION UNDER THE LIABILITY COVERAGE FOR: <br />CITY OF CARSON ISAOA; CITY OF SANTA ANA ISAOA;CITY OF RIVERSIDE. <br />0681 /07236 <br />155 7 66 CA 2 05-2002 (o1 a0251c) (o1 a0254c) <br />13SX0 (ola025vd) <br />Agent: SKALA INSURANCE AC <br />Telephone: (909)883-8861 <br />Prepared DEC 04 2019 750 <br />a N_oaa Risk Managzmerd'Divisian <br />REVIEWED & APPROVED BY.- <br />4 <br />f R. Vj&wd <br />® Risk Management Analyst <br />