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APPENDIX C Sample Insurance Forms <br />(Continued) <br />Sample Certificate of Liability Form <br />Ac ,�n_ CERTIFICATE 4F LIABILITY INSURANCE "1111°°""' <br />11J12/97 <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 />204 Cedar Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. <br />Cambridge ND 21613 COMPANIES AFFORDING COVERAGE <br />G. Philip Feldman COMPANY <br />Ph—N0. 410-228-6464 A Federal Insurance Company <br />INSURED <br />COMPANY <br />B <br />COMPANY <br />C <br />COMPANY <br />D <br />COVERAGES <br />"THIS <br />IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE MURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED, NOTWITHSTANDING ANY REOLWEMENT. TERM OR CONOMON 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 SU@JECT TO ALL THE TERM, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIAITS SHOWN MAY HAVE BEEN REDUCED BY PND CLAIMS. <br />LTR <br />TYPE oP INSURANee <br />POucY NUMBER <br />POLICY EFFECTIVE <br />(MMIDWYY) <br />POUCY EXPIRATICNN <br />DATEPMAUDDTYY) <br />LWris <br />GENERAL UANUTY <br />GENERAL AGGREGATE s2, 000 000 <br />A <br />X COMNAERCIALGENERALUABATIY <br />04/01/97 <br />04/01/98 <br />PRODUCTS •COMPAPAGG $2#000, <br />cLAxASMADEaOCCUR <br />PERSONALAADYINJURY $1 000 000 <br />EACH OCCURRENCE $1,000,000 <br />Ow"etS a CONTRACTOR'S PROT <br />A <br />X Computer Software <br />04/01/97 <br />04/01/98 <br />FIRE DAMAGE (MYpuln) $Included <br />L Svcs E60 <br />MEOEXP (AnYawPwaM) s 10,000 <br />$1,000,006 CAM" yaps <br />;AUTOMOBILE <br />- <br />LIABILITY <br />AtY AUTO <br />COMBINED SINGLE LIACI $ 1 , 0 o 0 , 000 <br />�- <br />i <br />I ALL OWNED AUTOS <br />SCHEDULED AUTOS <br />@DOILY "JURY $ <br />(P- P—) <br />A <br />, X <br />Ox- <br />HREDAUTOS <br />NON -OWNED AUTO! <br />04/01/97 <br />04/01/98 <br />"SOMY WARY $ <br />(Pw KCMeI4 <br />PROPERTY DAMAGE s <br />E <br />GARAGE LIABILITY <br />I AUTO ONLY . PJI ACCIDENT s <br />AN7 AUTO <br />I OTHER THAN AUTO ONLY: <br />I EACH ACCIDENT S <br />AGGREGATE s <br />EXCESS LIABJUTY <br />EACH OCCURRENCE S <br />tR,I3RELLA FORM <br />AGGREGATE s <br />OTHER THAN UMBRELLA FORM <br />$ <br />WORKERS COMPENSATION AND <br />EMPLOYERS' UABILRY <br />WC STATU. <br />TORY U,% R <br />EL EACH ACCIDENT f <br />THE PROPRIETOR( <br />PARTNERS7EXEC TTIVE <br />EL OxSF.ASESPOLICY LIMIT s <br />EL DISEASE. • EA EMPLOYEE $ <br />OFFICERS ARE EXCL <br />OTHER <br />dWX.ESISPECU <br />I <br />DESCRIPTION OF OPERATWNSAOCATIONS . ITEMS <br />CERTIFICATE HOLDER <br />CANCELLATION <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE <br />CITY OF SANTA ANA, ITS OFFICERS. AGENTS APUD <br />EXPIRATOONDATETHKREOF,THEIssUINOCOkWANYWTLLeeBlIMeRRVMAR. <br />F ktPI.OYEES <br />30 OAYSWMTTEN NOTICE TO THE CERTIFICATE NDLDER NAMED TO THE LEFT. <br />P.O. BOX 1988 <br />SANTA ANA- CA 92702 <br />AUTHORIZED REPREIEWMFFE � SN�-w, <br />G. Philip Feldman , <br />r XCACORD <br />AGORD 26S (1186) `.. <br />CORPORATION! 1922 <br />City of Santa Ana Page 38 of 39 <br />Exhibit A <br />