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<br />.. <br /> <br />,-,e;;I "r - I-L-UI-e;; VJ ..L '"~''''' ....'..L-e;; <br />Sparta Program <br /> <br />./ <br />Name Insured: <br />JWU1 Daniel <br />839 N. Kintyre Drive <br />Orange, CA 92869 <br /> <br />Certifkate # <br /> <br />Coverage <br /> <br />Limits <br /> <br />OOOuctibles <br /> <br />Tenns& ' <br />Couditioas <br /> <br />Exclusions <br /> <br />Named Additional Insured: <br />SANTA ANA (SPARTA) <br />20 Civic Center Plaza PO Box 1988 <br />Santa Ana CA 92701 <br /> <br />SSA02-0017 <br /> <br />SPARTA INSURANCE PROGRAM: Commercial General Liability - Hazard 1 <br />Contract Value: $98,000.00 <br />Coverage Period: 10/112003 to 10/l/2004 <br />Insurance Carrier: Essex Insurance Company <br />Master Policy: 3CJ8801 <br />Master Policy E1Ièctive Date: 1111512002 to expiration <br /> <br />$2,000,000 General Aggregate I $1,000,000 Each occurrence I $1,000,000 Products/Completed operations I $1,000,000 <br />Personal & Advertising Injwy1S50,000 Fire Damage I Medical Payments Excluded I $1,000,000 Non-owned <br />Automobile Liability"OOWrage-iòr1he city, county or public entity only. No coverage is provided Iòr the Certificate <br />Holder. Coverage is limited to the insured operation covered by this certificate and fur velúcles not owned or hired by the <br />city, county or public entity. <br /> <br />$50~ BI & PD Per Claimant Including Loss Adjustment Expense <br /> <br />$1,000.00 Premium (Fully Earned) <br />$31.25 Taxes (Fully Earned) <br />$75.00 Certificate Fee (Fully Earned) <br /> <br />$1,106.25 Total Amt <br /> <br />I. No Cancellations Allowed. Premium, taxes and fees are fully earned at inception. <br />2. Operations and Rating Based: Consultant - No public exposure - provide LAN Network maintenance & support, <br />train users various software related tasks & development projects. <br />3. Contractual on a Limited Form. NO PROFESSIONAL UABIIl1Y COVERAGE PROVIDED. <br />4. Additionallnsured(s): N/A <br />5. Department: Community Development Agency, City of Santa Ana, Housing Authority. <br />6. Please see the attached quotation Iòr federally mandated terrorism coverage. (This premium IS NOT included in your <br />quote.) See attached quote. <br />6. Sparta Non Owned Auto restricted to the private passenger vehicle of Daniel Juan. <br /> <br />Asbestos, Assault & Battery, Employer Related Practices, Subsidence, Independent Contractors, Pollution, Cross Suit, <br />Lead or Silica Dust, Mold or Bio-organic Growth or Mildew, Punitive Damages, Auimal, Breach of Contract, Y2K <br />Electronic Data, Medical Payments, War or Terrorism. <br />The insurance provided under this policy is limited to your work perIòrmed on behalf of the entity named as "Additioual <br />Named Insured" above and doesn't extend itself to any other work perfurmed by)'Oll or your organization. Coverage is <br />limited to the description of operations and rating bases listed in "Terms & Conditions" item 2. <br />The Terrorism Risk Insurance Act of 2002, requires us to offer you a quote fOr terrorism coverage. This Quotation is <br />separate and not included in your coverage premium. This coverage must be accepted or rejected by )'011 and the <br />attached form returned to us prior to binding. <br />Per the Master policy, a copy is available by written request to: Municipality 1nsW1UJCe Services, Inc. 1920 East 17th St <br />Suite 136, Santa Ana, CA 92705 . <br /> <br />APPROVED AS '10 FORM <br /> <br />Li!6f¿d: - ?/ 7 <br /> <br />Deputy City A.ttorney <br /> <br /> <br />~ <br />/Z; ~-- <br />- - <br /> <br />Carol Frost I President <br />Municipality Insurance Services, Inc. <br /> <br />1920 East 17th St Suite 136 Santa Ana, CA 92705 (800) 420-0555 (714) 550-5040 fax (714) 550-5044 License# OC04849 <br />