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- Account Number: CA SUSA 1650 Date: 2/27/04 Initials: VM <br />CERTIFICATE OF INSURANCE <br />EXECUTIVE RISK INDEMNITY INC. <br />C/O: American Professional Agency, Inc. <br />95 Broadway, Amityville, NY 11701 <br />This is to cart ity that the insurance policies specified below have been issued by the c>a pany indicated <br />above to the insured named herein and that, subject to their provisions and conditions, such policies afford <br />the coverages indicated insofar es such coverages apply [o the occupation or business of the Named insureds) <br />as stated. <br />THIS CERTIFICATE OF INSURANCE NEITHER AFFIRMATIVELY NOR NEGATIVELY AMENDS, ESTENDS OR <br />ALTERS THE COVERAGES) AFFORDED BY THE POLICY(IES) LISTED ON THIS CERTIFICATE. <br />Name and Address of Insured: <br />SUSAN SAXE-CLIFFORD,PH.D <br />A PROFESSIONAL CORP. <br />16530 VENTURA BLVD. <br />SUITE 203 <br />ENCINO, CA 91436 <br />Type of Work Covered: PROFESSIONAL PSYCHOLOGIST <br />Location of Operations: N/A <br />(If different than address listed above) <br />Claim History: <br />Additional Named Insureds: <br />SUAN SAXE-CLIFFORD, PH.D <br />~ -,~ 00 3 - .~ ~ 7 <br /> Policy Effective Expiration Limits of <br />Coverages Number Date Date Liability <br />PROFESSIONAL/ 1,000,000 <br />LIABILITY 008-OOOOG00 3101/04 3/01/05 3,000,000 <br />NOTICE OF CANCELLATION WILL ONLY HE GIVEN TO THE FIRST NAMED INSURED ON THIS <br />POLICY AND HE OR SHE SHALL ACT ON BEHALF OF ALL INSUREDS WITH RESPECT TO GIVING <br />OR RECEIVING NOTICE OF CANCELLATION. <br />Comments: <br />This Certificate Issued to <br />Name: SUSAN SAXE-CLIFFORD,PH.D <br />A PROFESSIONAL CORP. <br />Address: 16530 VENTURA BLVD. <br />SUITE 203 <br />ENCINO, CA 91436' <br />~~~ <br />ized Representative <br />