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Usa B. Done, D.V.M. <br />1121 Wind Ward Way <br />Oxnard, CA 93035-2459 <br />II►11►roil 1111111111►1111►1►I1I►1loll i►1►1►i.►►►111►►►11111111 <br />k' 1 '0 3 �_ 14/ <br />AVMA Professional Liability Insurance Trust <br />P. O. Box 1629, Chicago, IL 60690-1629 <br />FOR INFORMATION, OR <br />TO MAKE A COMPLAINT, <br />PLEASE CALL (800) 228-7548 <br />ITEM 2 Gi dA*Ss 1100 Fro+w 1/D1120D3 To 1/01/2004+201A.M.sve►a.►dTl�►Wat#*►.dk*Wvr-►t»�w.am+s�++�erein. - <br />:.:.:::: <br />ITEM 3 The Insurance ~dad Is only with respect to such and so many of the following eotrerages as ere indlcafed <br />by a specific annual premium charge shown balm. <br />'ERAGE A - PRIMARY PROFESSIONAL UABIU Y LIMITS <br />$100,000 each claim / $300,000 aggregate <br />PRIMARY <br />nber Name Member No. IRC CLASS PL -PREM <br />Jsa Beth Done 146011 42 IV $ 147 <br />A <br />h <br />rms CLD36A 0102; CLD36C 0195; CLD35D 0195; CLD36M 0195; CLD36E 01 95 <br />pilcable: <br />As of Issue <br />10/11/2002 REN <br />a au e12002 <br />14-4 OF <br />President <br />Producer MACK AND <br />$ 147.00 <br />WVUE 1 $ 147.00 <br />KER, INC. <br />Countersignature of Authorized Agent <br />A"k aud- &.4"., f". * <br />tearr here F Go to www.avmaoik.com to make changes and pay your premium. fear hers -P <br />11 irm tFroTrisurance Rating Code (IRC) and my mailing address shown shove is correct. <br />1 would like my certificate changed as Indicated on the attached Change Request Form. DUE DATE: 1/01/2003 <br />Payment options: 13 Check enclosed ❑ Money Order [3Vias ❑ Mastercard Amount Enclosed/Charged: $ <br />To pay by credit card, please compote #w following: (craft cad aerm•n► ea wdwas In NoM CAro a) <br />Card ►xlmber Explrador► due: PVOMA PUT <br />t1 tOf ficer <br />"Cndruld 4iginp rddrses ChICag4 It t <br />. <br />Phone_WO�2M7546 <br />Caniholderefpnot►rn: Nintnerds:; www.a mapliteom <br />Signature of Insured Data <br />Do not withhold payment pending receipt of adjusted billing as this could cause cancellation of coverage. <br />060878 030101 00014700 0026267000 8 <br />_--..APFROVED—AS TO FORM-----.-- <br />`-- <br />Laura Speedy <br />Deputy City Attorney ,r. <br />Z :abed Z" -Z96 (S09) 138uu03 Ia;ul Wd b6:L 3a £0/£!9 <br />