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I EVIDENCE OF CONTRACT OF POOLED SELF.INSURANCE !ISSUE DATE 7/11/2007 ALLlANT INSURANCE SERVICES, INC. THIS EVIDENCE OF CONTRACT IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO P.O. BOX 6450 RIGHTS UPON THE HOLDER. THIS DOES NOT AMEND, NEWPORT BEACH, CA 92658-6450 EXTEND, OR ALTER THE COVERAGE AFFORDED BY (949) 756-0271 FAX # (949) 756-2713 THE CONTRACT DESCRIBED BELOW. COVERAGE AFFORDED BY . INSURED CALIFORNIA INSURANCE POOL AUTHORITY LETTER A: INDIVIDUAL CITY'S SELF-INSURED RETENTION AND MEMBER AGENCY OF: CITY OF BUENA PARK LETTER B: "California Insurance Pool Authority, A Public Agency." 6650 BEACH BLVD BUENA PARK, CA 90621 . MEMBER AGENCY OF THE CALIFORNIA INSURANCE POOL AUTHORITY COVERAGE PER CA. GOVERNMENT CODE SECTION 990.4(a), 990.8(c) THIS IS TO CERTIFY THAT THE PARTY NAMED ABOVE HAS ENTERED INTO A CONTRACT OF POOLED SELF- INSURANCE AS LISTED BELOW FOR CONTRACT PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS EVIDENCE OF SELF-INSURANCE MAY BE ISSUED OR MAY PERTAIN, THE COVERAGE AFFORDED BY SELF-INSURANCE CONTRACT DESCRIBED HERE IS SUBJECT TO ALL THE TERMS, EXCLUSIONS, AND CONDITIONS OF THE CONTRACT OF SELF-INSURANCE. CONTRACT CONTRACT CONTRACT LIABILITY LIMITS IN THOUSANDS LTR TYPE OF COVERAGE NUMBER EFFECTIVE EXPIRATION EACH AGGREGATE DATE DATE OCCURRENCE A GENERAL AND AUTOMOBILE SELF INSURED 07/01107 07/01/08 LIABILITY INCLUDING PUBLIC BI&PD 500, N/A OFFICIALS ERRORS AND COMBINED OMISSIONS PERSONAL INJURY $ INCL. B EXCESS LIABILITY CIPA 006 07101107 07101/08 BI &PD 1,500, $ 20,000, COMBINED - DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I SPECIAL ITEMS 1 COUNTYWIDE PUBLIC FINANCING AUTHORITY 1996 REVENUE BONDS LEASE AGREEMENT FOR COUNTYWIDE 800 MHZ COMMUNICATIONS SYSTEM. SUBJECT TO POLICY TERMS, CONDITIONS AND EXCLUSIONS. Af>j',1#!jVlewY 1; e7f: -(); Y '''THE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID LOSSES CO CERTIFICATE HOLDER I CANCELLATION I SHOULD ANY OF THE ABOVE DESCR/BED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAil JQ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED HEREIN BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KJND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. SUBJECT TO 10 DAYS NOTICE OF CANCELLATION FOR COUNTYWIDE PUBLIC FINANCING AUTHORITY NON.PAYMENT OF PREMIUM. ATTN: TREASURER AUTHORIZED SIGNATURE 20 CIVIC CENTER PLAZA SANTA ANA, CA 92701 ~~~ G\JPUnit\CIPA\Oc-Liability\Oc-Liab-Cer\ OC-liab-pn.doc x