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DRIVER - ALLIANT <br />License Number: SC36861 <br />Phone (949) 7M4271 / Fax (949) 756-2713 <br />Certificate Numbee043 Date: 1/24/05 <br />VENDOR / CONTRACTOR LIABILITY PROGRAM <br />Named Insured: <br />TOM BYSTRY <br />Address: <br />3058 WESTHAVEN STREET <br />City/State/Zip: <br />ORANGE, CA 92865 <br />Additional Insured; <br />CITY OF SANTA ANA <br />Contract Term: From: <br />02/01/05 TO 02/01/06 <br />Description of Contract: VIDEO TAPING CITY COUNCIL MEETINGS <br />Contract Amount $45,760.00 <br />COMMERCIAL GENERAL LIABILITY — NEW OCCURRENCE FORM <br />General Aggregate: <br />$1,000,000. <br />products/Completed Operations Limit: <br />$1,000,000. <br />Personal Advertising: <br />$1,000,000. <br />Each Occurrence: <br />$1,000,000. <br />Fire Damage: <br />S 50,000. <br />Medical Payments: <br />$ 5,000 <br />IMPORTANT! <br />Coverages are Limited to described contract. <br />DEDUCTIBLE: $1,000. Each Claim, Including Legal and Adjustment Expenses <br />ANNUAL PREMIUM: $686.00 Fully Earned at Inception <br />SURPLUS LINES TAX: $ 22.12 Fully Earned at Inception <br />POLICY FEE: S fQ.QQ Fully Earned at Inceptiou <br />TOTAL $758.12 <br />COMPANY: COLONY INSURANCE COMPANY <br />THIS COMPANY BINDS THE li'.IND(S) OF INSURANCE STIPULATED HEREON. THIS <br />INSURANCE IS SUBJECT TO THE TERMSUED , CONDITIONS, AND LO&TATIONS OF THIS POLICY <br />OF MASTER POLICY #G13215216 ISSTO VENDORS/CONTRACTORS LIABLITY GROUP. A <br />COPY OF THIS POLICY IS AVAILABLE ON REQUEST. <br />THIS CERTIFICATE MAY BE CANCELLED BY THE INSURED BY SURRENDER OF THIS <br />BINDER OR BY WRr TEN NOTICE TO THE COMPANY STATING WHEN CANCELLATION WILL <br />BE EFFECTIVE. THIS CERTIFICATE MAY BE CANCELLED BY THE COMPANY BY NOTICE TO <br />THE INSMg R�N, W TJ pOLTCY CONDTTIONS. <br />AUTHO '''(RIZZEEDvD SIGNATURE/COUNTERSIGNATURE <br />/COOUNTERSFSI�IGGNIATURE <br />R.fi CHAIX k ASSOCIAM INSURANCE BROKERS ,INC. <br />ri=w Number. 0726213 <br />41 C rpomw Park, Suite 310, Irvine, CA 92606 <br />PHONE (949)7224177 1 FAX: (949)722 4172 <br />Aei'ROVED AS TO FORM <br />�r� dy <br />Aabistant City Attorney <br />