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<br />Page 1 oi2 .~ <br />, <br /> <br />Certificate of Insurance <br />Sparta Program <br /> <br />SSA04-0028 <br /> <br />Named Additional Insured: <br /> <br />SANTA ANA (SPARTA) <br />20 Civic Center Plaza PO Box 1988 <br />Santa Ana CA 9270 I <br /> <br />~-vL{/~t-t <br />Pr /f7V I <br /> <br />Name Insured: <br /> <br />Jorgensen, Kent <br />36 Windswept Way <br />Mission Viejo, CA 92692 <br /> <br />Certificate # <br /> <br />Coverage <br /> <br />Limits <br /> <br />Deductibles <br /> <br />Terms & <br />Conditions <br /> <br />Exclusions <br /> <br />SPARTA INSURANCE PROGRAM: Commercial General Liability - Hazard 2 <br />Contract Value: $150,000,00 <br />Coverage Period: 1/7/2005 to 1/7/2006 <br />Insurance Carrier: Essex Insurance Company <br />Master Policy: 3CP9777 <br />Master Policy Effective Date: 11/15/2004 to expiration <br /> <br />$2,000,000 General Aggregate 1 $1,000,000 Each occurrence 1 $1,000,000 Products/Completed operations 1 <br />$1,000,000 Personal & Advertising Injury/$50,000 Fire Damage 1 Medical Payments Excluded 1 Including <br />Non-owned Automobile Liability coverage for the city, county or public entity only. No coverage is provided for the <br />Certificate Holder. Coverage is limited to the insured operation covered by this certificate and for vehicles not owned <br />or hired by the city, county or public entity. <br /> <br />$500 BI & PO Per Claimant Inciud;ng Loss Adjustment Expense <br /> <br />$1,300.00 Premium (F"lly F.'med) <br />$41,93 Taxes (Fully Earm.,l) <br />$150.00 Certiticate Fee (Full) Earned) <br />TRIA <br /> <br />Total Amount <br /> <br />$1,491.93 <br /> <br />1. No Cancellations Allo\\ed. Premium, taxes and fees are fully earned at inception. <br />2. Operations and Rating Based: Consultant - Coordinate, monitor and implement City right of way activities. NO <br />CONSTRUCTION OPERATIONS COVERAGE PROVIDED. <br />3, Department: Public Works <br />4, Additionallnsured(s): Not Applicable <br />5. No Professional Liability Coverage provided. <br />6. NON OWNED AUTOMOBiLE liABiliTY COVERAGE IS FOR PRiVATE PASSENGER VEHiCLE ONL Y. <br /> <br />Asbestos, Assault & Battery, Employer Related Practices, Subsidence, Independent Contractors, Pollution, Cross <br />Suit, Lead or Silica Dust, Mold or Bio-organic Growth or Mildew, Punitive Damages, Animal, Breach of Contract, <br />Y2K Electronic Data, Medical Payments, War or Terrorism. <br />The insurance provided under this policy is limited to your work performed on behalf of the entity named as <br />"Additional Named Insured" above and doesn't extend itself to any other work performed by you or your <br />organization. Coverage is limited to the description of operations and rating bases listed in "Terms & Conditions" <br />item 2. <br /> <br />Per the Master policy, a copy is available by written request to: Municipality Insurance Services, lnc" 302 W. <br />Cerritos Ave., Building #7, Anaheim, CA 92805 <br /> <br />APPROVED AS TO FORM <br /> <br /> <br />Laura Sf t Sheedy <br />Assistant ity Attorney <br /> <br />302 W. Cerritos Ave Bldg# 7 Anaheim, CA 92805 (800) 420-0555 (714) 687-1100 fax (714) 687-1106 LicensesCA:OC04849: OR: I 95423 <br />Website address www.2sparta.com <br />