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Ceiticate of InsurancW <br />Sparta Program A -a oo3- oas <br />/ Npme Insured: Named Additional Insured: <br />Omdorff, Jon <br />112 Second Street, Apt. #2 <br />Seal Beach, CA 90740 <br />SANTA ANA (SPARTA) Bordereau <br />20 Civic Center Plaza PO Box 1988 <br />Santa Ana CA 92701 <br />Certificate # <br />SSA03-0018 <br />Coverage <br />SPARTA INSURANCE PROGRAM: Commercial General Liability - Hazard 1 <br />Contract Value: $50,000.00 <br />Coverage Period: 2/26/2004 to 2/26/2005 <br />Insurance Carrier: Essex Insurance Company <br />Master Policy: 3CM4080 <br />Master Policy Effective Date: 11/15/2003 to expiration <br />Limits <br />$2,000,000 General Aggregate / $1,000,000 Each occurrence / $1,000,000 Products/Completed operations / <br />$1,000,000 Personal & Advertising Injury/$50,000 Fire Damage / Medical Payments Excluded / $1,000,000 <br />Non -owned Automobile Liability coverage for the city, county or public entity only. No coverage is provided for the <br />Certificate Holder. Coverage is limited to the insured operation covered by this certificate and for vehicles not owned <br />or hired by the city, county or public entity. <br />Deductibles <br />$500 BI & PD Per Claimant Including Loss Adjustment Expense <br />$1,000.00 Premium (Fully Earned) <br />$31.25 Taxes (Fully Earned) <br />$75.00 Certificate Fee (Fully Earned) <br />TRIA <br />$1,106.25 Total Amount <br />Terms & <br />1. No Cancellations Al!owed. Premium, taxes and fees are fully earned at inception. <br />Conditions <br />2. Operations and Rating Based: Consultant : No Public Exposure working with personnel of the Public Works of <br />Santa Ana fixing and maintaining their Database and various computer assisted drawings (CAD). <br />3. Department: Public Works City of Santa Ana <br />4. Additional Insured(s): Not Applicable <br />5. NO PROFESSIONAL LIABILITY COVERAGE PROVIDED. <br />6. NON OWNED AUTO LIABILITY COVERAGE IS FOR A PRIVATE PASSENGER VEHICLE ONLY. <br />7. NO PUBLIC EXPOSURE WORKING WITH THE CITY OF SANTA ANA AND THEIR DEPARTMENTS <br />ONLY. <br />Exclusions Asbestos, Assault & Battery, Employer Related Practices, Subsidence, Independent Contractors, Pollution, Cross <br />Suit, Lead or Silica Dust, Mold or Bio -organic Growth or Mildew, Punitive Damages, Animal, Breach of Contract, <br />Y2K Electronic Data, Medical Payments, War or Terrorism. <br />The insurance provided under this policy is limited to your work performed on behalf of the entity named as <br />"Additional Named Insured" above and doesn't extend itself to any other work performed by you or your <br />organization. Coverage is limited to the description of operations and rating bases listed in "Terms & Conditions" <br />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 you 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 I surance Services, Inc. 1920 East 17th <br />St Suite 136, Santa Ana, CA 92705 ROVED JA TO FORM <br />Michael Vigliotta <br />Deputy City Attorney <br />1920 East 17th St Suite 136 Santa Ana, CA 92705 (800) 420-0555 (714) 550-5040 fax (714) 550-5044 License# 0004849 <br />