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APPENDIX C Sample Insurance Forms <br />(Continued) <br />Sample Certificate of Liability Form <br />AC-0,80. CERTIFICATE OF LIABILITY INSURANCE 11 /12 DATE/12 /9 <br />/97 <br />PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION <br /> ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE <br />Insurance Services Group, Inc. HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR <br /> ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. <br />204 Cedar Street <br />Cambridge HD 21613 COMPANIES AFFORDING COVERAGE <br />0. Philip Feldman COMPANY <br />A Federal Insurance Company <br />P11 N. 410-228-6464_ &.N. <br />INSURED COMPANY <br /> B <br /> COMPANY <br /> C <br /> COMPANY <br /> D <br />COVERAGES :.; . <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED, NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TEPJAS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> RANCe POLICY HUMBER POUCYEFFECTNE <br />DATE (MM)DD%YI POUCYEXPIRATION <br />DATE IMM)DWYI LIMITS <br /> GENERAL AGGREGATE $2,000 , 000 <br /> ERALUAB'L Y <br />VCOMME-R-CftG-ENERALUAB'L-rT 04/01/97 04/01/98 PRODUcTs-COMPKIPAGG $2,000000 <br /> a OCCUR PERSONAL & ADV INJURY $ 1 , 00 0 , 000 <br /> ACTOR'S PROT EACH OCCURRENCE $1,000,000 <br />A X Computer Software 04/01/97 04/01/96 FIRE DAMAGE (Any aafa.) $ Included <br /> & Svcs E&O $1,000,000 CLAIM 1QDE MEDEXP(Any -p-) f 10,000 <br /> AUT OMOBILE LIABILITY <br />COMBINED SIJGLE LIMIT <br />$ 1,0D0,000 <br /> ANY AVID <br /> ALL OWNED AUTOS BODILY INARY <br />S <br /> SOHEDIJLEO AUTOS (Pe P- 4 <br />A X HIREDAVTOS 04/01/97 04/01/98 BOCILYIAMY f <br /> X NON-OWNED AUTOS (Pm *Cad-4 <br /> <br /> PROPERTY DAMAGE S <br /> <br /> GARAGE LIABILITY AUTO ONLY • EA ACCIDENT S _ <br /> ANY AUTO OTHER THAN AUTO C#A.Y: <br /> EACH ACCIDENT $ <br /> AGGREGATE S <br /> EXCESSLIA"11Y EACH OCCURRENCE <br />- S <br />. <br /> UMBRELLA FORM AGGREGATE <br />.. $ <br /> OTHER THAN UMBRELLA FORM S <br /> WORKERS COMPENSATION AND y/C <br />T IjM?IT$ ER <br /> EMPLOYERSLIABKITY <br />EL EACH ACCIDENT <br />S <br /> l#PROPRIETOR/ IN _ <br />EL DISEASE, POLICY LIMIT f <br /> P <br />ARTNERSIEXECUTIVE <br />OFFICERS ARE: <br />EXCL <br />'. EL DISEASE, EA EMPLOYEE <br />I <br /> OTHER <br />DESCRIPTION OF OPERATIONSR.OCATIONSNEMMES(SPECM ITEMS <br />CERTIFICATE HOLDER <br />. CANCELI:ATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE <br />CITY OF SANTA ANA. ITS OFFICERS, AGENTS AND EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL E11146"WRW MAIL <br />EMPLOYEES 30 DAYS YITNTTEN NOTICE TO THE CERT)FICATE HOLDER NAMED TO THE LEFT, <br />P.O. BOX 1988 <br />SANTA ANA. CA 92702 <br /> AUTHORRED REPRESENTATIVE <br />q <br /> G. Philip Teldman / <br />AGOTRD 2tSv^,17/85) mACORD'CORPORATION 1988 <br />City of Santa Ana <br />Page 38 of 39 <br />25C-50 Exhibit A