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<br />APPENDIX D <br />(Continued) <br /> <br />Sample Insurance Forms <br /> <br />Sample Certificate of Liability Form <br /> <br />ACORD. <br /> <br />CERTIFIQATEOF'lIABILlTYINSURANC~c~l 0'~7~~ <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION <br />ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE <br />HOLDER. THIS CERTlFlCATE DOES NOT AMEND, EXTEND OR <br />ALTER THE COVERAGE AFfORDED BY THE POLICIES BELOW. <br />COMPANIES AFFORDING COVERAGE <br /> <br />Group lIne.. <br /> <br />PROrAJCER <br /> <br />Insurance Services <br />204 Cedar street <br />Cambridge Me 21613 <br />G. Philip Feldman <br />PII.....No. 410 228-6464 <br />INSURED <br /> <br />FnNo. <br /> <br />"""".." <br />A <br /> <br />Federal Insurance Company <br /> <br />COMP"" <br />9 <br /> <br />APR CONSULTING, INC. <br />Mr. Darryl stone <br />22632 Golden Springs Dr., '330 <br />Diamond Bar CA 91765 <br /> <br />COt.lPANY <br />C <br /> <br /><x...."" <br />o <br /> <br />COVEFY'GE$\- ""~, 'f.:;:),;.:;::., "\-- \V' 'W v:: <br />THIS IS TO CERnFV THAT THE POLICIES OF INSURANCE USTEO BELOW HAVE 8EEN ISSUED TO THE INSURED NAMEO ABOve FOR THE POlICY PERIOD <br />INDICATED, NOTWITHSTANDING IN( REQUlRErVENT, TERM OR CONDITION OF /IN( CONTRACT OR OTHER OOCUMENTWITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, TH! INSURANCE AfFORDED BY THI! POLICIES DESCRIBED HEREIN IS SUBJECT TO All THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POUCIES. lIMTS SHOWN MAY HAVE BEEN REDUCeD BY PAlO ct..ANS. <br /> <br />'0 <br />m <br /> <br />TYPE OF INSlIl'tAHC1! <br /> <br />I"OUCYNUMIl!Jlt <br /> <br />POlICYEFFECTlYI! POliCY EXPIRATION LIMITS <br />DATEIMMlDDIYY) DATE IMMIDDNVI <br /> GENEAAL AGGREGATE .2 ODD 000 <br />04/01/97 04/01/99 PROOUCTS. COMPIOP ....00 '2 000 ODD <br /> PERSONAL & ADV INJURY n ODD ODD <br /> EACH OCCURRENCE t 1 000,000 <br />04/01/97 04/01/98 FIRE DAMAGE (Any OIl. fir.) t Included <br /> MEa EXP (Anr "".~J . 10 000 <br /> COMBlNEO SINGLE lNlT' . 1,000,000 <br /> SODIlYlNJIJRY . <br /> (l""~J <br />04/01/97 04/01/98 BODILY INJURY . <br /> (l"erecciden'(l <br /> PROPERTY DAMAGE . <br /> <br />~ElW.lIA.BlLlTY <br />A ~ ~eRCIAL.GeNeRAl.lIA81l..1TY <br />~_~LAIMS MADE W OCCUR <br />OWNER'S & COHTRACTDR'S PRaT <br />A X Computer Software <br />" SVClS E&O <br />AlJTOMOBlLEllABlUTY <br />ANY AUTO <br />AU. OWNED AUTOS <br />SCHEOULED ....UTOS <br />A X H1REDAVTOS <br />X NON.QWNED Al1l'OS <br /> <br />3532-61-16 CCG <br /> <br />3532-61-16 <br /> <br />.1,000,000 CLA%KlIIAD. <br /> <br />3532-61-16 CCG <br /> <br />- <br /> <br />~;~:~"' <br /> <br /> <br />EXCeUl..lA8lLlTY <br />RUMBflELl.,l,FORM <br />OTHER 'THAN UMBREll.A FOftM <br />WORK!flS COMPENSATION AND <br />I!MPLOYI!RS'lIA.IlIUTY <br />TlE PROPRIETOAI R""" <br />PAATNERS/EXECUTlVE <br />OFFICERS ARE: exCL <br />"'"'" <br /> <br />AVTOONlY.EAACClOENT t <br />OTHEATHAN....UTOONlY: .':'.: ;':". <br />EACH ACCIDENT S <br />I.GGREGATE t <br />EACH OCCURReNCE t <br />....GGREGATE t <br />. <br />f~r-~s I"m::.;':::;:;-. >>. <br />ElEACHACCIDENT t <br />El OlSEASE . POLICY LIMIT t <br />a. DISEASE. EA EMPLOVEE t <br /> <br />DESCRIPTlOH OF OPERATIONS/l.OCATlONSNEHlCLUlSPa:lAL ITEMS <br /> <br />>.>. ; <br /> <br />.. <br /> <br />. <br />SHOUlDANY OF THI! ABOVI! DESCRIBED POLICIES BE CANCEllEO BEFOItE THE <br />DPlMTIONDAT1! THl!ftI!OP, THI! ISSUING ~""NY WIll MAIL <br />~OAYS Wll:lTTl!N NOTICE TO THI! CERTIFICATE HOLDER HAMnl TO THELI!l"'T, <br /> <br />CITY OF SANTA ANA, ITS OFFICERS. AGENTS AND <br />EMPLOYEES <br />P.O BOX 1988 <br />SANTA ANA, CA 92702 <br /> <br />> <br /> <br />~,nJ <br />....UTHOfIlIZI!OREPRESI!NT...TlV.I!: , II _ '1. i VN, <br />IG r~'~'''' ..__n_. <br />. PhiliP. >.;. ~..QQROCO""OllATION.1'" <br /> <br />Page 33 of 35 <br />