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<br />y' II I r'1 LtJ..'" i l. ~!J <br /> <br />t r ~"'t.........~...1 <br /> <br />~ 2/10/2004 15:24 <br /> <br />It ;;CX)'3' I i '2.. Burnet te Insurance <br /> <br />Pam Flowers->LALRA SHEEDY <br /> <br />2/2 <br /> <br />ACORD. CERTIFICATE OF LIABILITY INSURANCE CSR PF I DATE {MMlDofVYYY) <br />SYMCO-l 02/10/04 <br />PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION <br /> ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE <br />Burnette Insurance Agency,Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR <br />3447 Lawrenceville Suwanee Rd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. <br />Suwanee GA 30024-2402 <br />Phone: 170-339-8888 Fax: 770-339-1442 INSURERS AFFORDING COVERAGE NAlC# <br />INSURED A-d.OO/~ 18tJ INSURER A Zurich U.s. Insurance <br /> 4,.2Do~~ I INSURERS Legion Insurance Camnany <br /> INSURERC' <br /> Sma Grou~, Inj' ;{.~d.IX8'//)- <br /> 3 73 MaCa! Dr 1 INSURER 0 <br /> Atlanta GA 30340-2831 <br /> INSURERE <br /> <br />COVERAGES <br /> <br />THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING <br />NN REQUIREMENT, TERM OR CONDITION OF NN CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CEIUIFICATE MAY BE ISSUED OR <br />MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH <br />POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />,.",. POUCY NUMBER p~~r'::M~ P~ieY ~~":J:~~ <br />LTR .S" TYPE OF INSURANCE UMOTS <br /> ~ERALUA8IUTY EACH OCCURRENCE '1,000,000 <br />A X COMMERCIAL GENERAL UABIUTY 040972979 07/31/03 07/31/04 I ~~J?E~~~~~~nce) . 300,000 <br /> 1 Cl.AIMSMAOE [!] OCCUR MED EXP (Nly one person) '10,000 <br /> "- PERSONAL & MN INJURY $ 1,000 I 000 <br /> "- GENERAL AGGREGATE . 2,000,000 <br /> / !i;'LAGGREGAnl~::ueSn I PRODUCTS-COMPIOPAGG .2,000,000 <br /> :J: ,POUCY JECT LeC <br /> ~MOBILllWlILJTY COMBtNEO SINGLE UMIT .1,000,000 I <br />A c.!. AH'fAJJTO 040972979 07/31/03 07/31/04 (Eaacclcl!nt) <br /> I- ALL O'MIlEO AJJTOS BOOIL Y INJURY <br /> . <br /> I- SCHEOULEDAJJTOS (Per person) <br /> c.!. HIRI:D AUTOS BOOILYINJURY <br /> . <br /> c.!. NON-O'M'OED AUTOS (PeraCclcent) <br /> i-- PROPERTY DAMAGE . <br /> (Peracclcent) <br /> =is UAalUTY AUTO ONLY - EAACCIDENT . <br /> NNAJJTO NOT APPLICAIlLE OTHER THAN EAACC . <br /> AUTO ONLY. AGO . <br /> 51lJUMBREUA UABIUTY EACH OCCURRENCE '1 000,000 <br />A I OCCUR 0 CLAIMS MADE 040972979 07/31/03 07/31/04 AGGREGATE .1,000,000 i <br /> . I <br /> ~~eOUCT"r.E . I <br /> X RETENTION .0 . I <br /> WORKIIRI COMPENlAnON AND : [T~l:~TATll- I IO:~ I <br /> X TORy UMITS <br />B EMPLOYERS' UAlIUT'f WC50548357 11/28/03 11/28/04 <br />NN PROPRIETORiPARTNERiEXECUTIVE EL EACH ACCIDENT .100,000 <br /> OFFICERlMEMBER EXCLUDED? EL DISEASE. EA EMPLOYEE '100,000 <br /> ll''(es.cescl1{)euncer <br /> SPEClALPROV1SIONSoelow EL. DISEASE. POUCY UMIT . 500,000 <br /> OTHER I <br /> I <br /> I <br />DESCRlI'nON OF OPERA-nONS' LOCAnONl/VEHICLIISI IXCLU810N8 ADDED BY ENDORSEMENT 18PECIAl. PROVISIONS tr t {l.PPROVE1) ..i- (,~ TO F01'(]\.1 I <br />Certificate holder is listed as additional insured as per con sc ua " .J......~ I <br />obligation./Faxed 714-647-5406. SEE REVISED WC INFORMATION. <br /> "--~~.I//l..--..._... <br /> I <br /> Laurel S~"tt S.,t;',~,J',' i <br /> ASsistan~ City /.ttor~-;"~\ i <br /> <br />CERTIFICATE HOLDER <br /> <br />CANCELLATION <br /> <br />DATE THER.EOF, nlE ISSUING INSURER. WILL ENDEAVOR TO MAlL <br /> <br />30 <br /> <br />I <br /> <br />SANTAAN <br /> <br />SHOULD ANY OF nlE ABOVE DESCRIBED POUCIES 8E CANCEL1.EO BefORE THE EXPlRATlON <br /> <br />OAYSWRrrTEN <br /> <br />City of Santa Ana <br />Linda Kelley <br />20 Civic Center Plaza <br />Sant-a Ana CA 92702 <br /> <br />NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE U!FT, BUTFAILURa TO 00 SO SHAll <br />IMPOSE NO OBUGATlON OR UABILITY OF ANY KIND UPON THE 1~ISUR!:;t ITS AGENTS OR <br /> <br />ar()~n ';'I?nnllnR\ <br /> <br />_!:EPR!:SENTATIVES. <br /> <br />A~;;:;r;;::."i- ~ <br /> <br />m AC'":C'lRn r:nRPnF?ATlnN Hl):j <br />