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<br />rClllll2 Municipali ty Cf!lf[pfdte1IJJffi'/iirancl!t
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<br />Sparta Program
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<br />! 'l'~me Insured:
<br />~o/gensen. Kent
<br />36 Windswept Way
<br />Mission Viejo, CA 92692
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<br />JertifiC3te # SSA04-0028
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<br />d.[ verage SPARTA INSURANCE PROGRAM Commercial General Liability _ Hazard 2
<br />Contract Value: $150,000.00
<br />I Coverage Period: 1/7/2004 to 1/7/2005
<br />Insurance Carrier: Essex Insurance Company
<br />, Master Policy: 3CP9777
<br />Master Policy Effective Date: 11/15/2004 to expiration
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<br />1/7/2005 9:46 AM
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<br />Terms &
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<br />C'USiODS
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<br />Named AdditioDalln,ured:
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<br />SANTA ANA (SPARTA)
<br />20 Civic Center Plaza PO Box 1988
<br />Santa Ana CA 92701
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<br />II, I
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<br />$2,000,000 General Aggregate / $1,000,000 Each occurrence / $1,000,000 Products/Completed operations /
<br />$1 ,000,000 ~ersonal & Advertising Injwy/$50,000 Fire Damage / Medical Payments Excluded / Including Non-awned
<br />Automobile Liability boverage for the city, county or public entity only. No coverage is provided for the Certificate
<br />Holder. COVeIage is likted to the insured operation covered by this certificate and far vehicles Dat owned or hired by
<br />the city, ca"'1ty or public entity.
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<br />$500 BI & PD Per Claimant Including Loss Adjustment Expense
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<br />$1,300.00 Premium (Fully Earned)
<br />$41.93 Taxes (Fully Eamed)
<br />$150.00 Certificate Fee (Fully Earned)
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<br />TRIA
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<br />$1,491.93 Total Amount
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<br />I. No Cancellations Allowed. Premiwn, laxes and fees are fully earned at inception.
<br />2. Operations and Rating Based: Consultant - Coordinate, manltor and implement City right of way activities. NO
<br />CONSTRUCTION OPERATIONS COVERAGE PROVIDED.
<br />3. Department: Public Works
<br />4. Additional Insured(s): Not Applicable
<br />5. No Professional Liability Coverage provided.
<br />6, NON OWNED AlITOMOBILE LIABILITY COVERAGE IS FOR PRIVATE PASSENGER VEIflCLE ONLY
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<br />Asbestos, Assault & Batte!)', Employer Related Practices, Subsidence, Independent Contractors, Pallution. Crass Sui~
<br />LOad or Sili';' Dus~ Mold or Bio-<>rganic Growth or Mildew, Punitive Damages, Animal. Breach of Contrac~ Y2K
<br />EI""~ D,ts, Medi~a1 Payments, War or Terrorism.
<br />The insuran,", provi~d under this policy jg limited to yaur wark perf armed an behalf af the entity named as
<br />"Additional J:lamed InSured" above and doesn't extend itself to any other work perfarmed by you or your organization.
<br />Coverage jg limited to the description of operations and rating b...esljgted in "Terms & Conditions" item 2,
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<br />Per the Master policy, a copy is available by written request to: Municipality Insurance Services, Inc., 302 W. Cerritos
<br />Ave" Building #7, Anaheim, CA 92805
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<br />APPROVED A,S TO FORM
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<br />/;?I"-U J-'-1
<br />Laura Stitt Sheedy
<br />Assistant City Attorney
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<br />Caral Frost / President
<br />Municipality Insurance Services. Inc.
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<br />i{02 W. Cerritos Ave Bldg# 7 Anaheim, CA 92805 \~?~;'~:~~r~:r ~~,~~. ~~~~o~o:x (714) 687.11 06 LicensesCAOC04849; OR:195423
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