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<br />05/05/2005 15:12 <br /> <br />7145714209 <br /> <br />PARKS AND RECREATION <br /> <br />PAGE 02 <br /> <br />FROM , GREGG CR~[J'/D STRTE FARM INS <br /> <br />poricy Number <br />92-QN75b9.2 <br /> <br />FRX NO. , 7145301006 <br />DECLARATIONS PAGE <br /> <br />Mar. 02 2005 EO: 2ePH P2 <br /> <br />AM~~CiED <br /> <br />;:::E "i' ?[i'~: <br /> <br />r;=: <br />~ <br /> <br />ST ATE FARM GiNEn....1NllURANCE COMPA.NY <br />900 OLD RIVER no, llAK.RSFIELO CA 93311.6000 <br />A STOCK COMPANY WITK KOME OFFICES IN BLDOMIN5TON,ILLlNO'S <br /> <br />Agen. Copy <br />Namac1,nsured "nd "'oiling Allllress <br />9643.F4 i 9 S <br />SENSE. ERIC M DR <br />5H. W 17TH .T STE C <br />SANTA ANA ':;A 92706-3619 <br /> <br />fI- ,d('{) 'f. (,;f,;( <br />.t'.. ;:J.oc4 D'f.J. ~()i <br /> <br />'. ~ ~ ur'1\~ VI <br />~ ...!(V \,J~~Jt' . <br />&-- r.:,v \: ~ <br /> <br />\C:-~~'~ <br /> <br />COy A -lnfUllion Cov<rraoe Index: 152.4 <br />BUSINESS POLICY - SPECIAL FORM 3 COy B . Consumer Price lndex: 185.2 . <br />AUTOMATIC RENE.....AL - II the POLJCY PERIOD is shown as 12 MONTHS, tl'ti".f.OIR will be r8llewed autornaticll!1v <br />5~bjetl to lhepl'l!miunlS. rules and fOl1l1s in eflecl for 'laCh sUIlO..cllnll DOliGy Pllno . I! lIlis polic,,- is termiQaled, WtI wi!) <br />g'Y6 you a~cl me Mori/llIgeelLienholder written nOliCa in complie,nClI WIlli IIle pOlley provisions or as required by law. <br />,"Olley Pc!riocI: 12 '-lO"I~S The policy period Deglns and enas al 12:01 am 911nQarQ time Illhe <br />Effl!Ctive Date: MA. v 12 2004 premises Iooalian. <br />ExpintiClnDBte: MAl' 12 2005 <br />Namec1lnwrQ(l: InooviClual <br /> <br />location 01 Co~ed PremIses: <br />516 W 17TI< STsn;: c <br />SANTA ANA CA 9~706.36t9 <br /> <br />Your policy is amOnded liEB 11 2005 <br />"DOL INSURED NAME & ADDRESS ,o,DDl;D <br />ENDORSEMENT liE-6320 ADDED <br /> <br />C"vllfagH . Property <br /> <br />Sechon I <br />^ Buildings <br />B Busines:s Personal!'rope"y <br />Closs ollncomo . 12 Monlh. <br /> <br />limhs of Insurance <br /> <br />eeup.ney; <br /> <br />Ice <br /> <br />i 263.000 <br />22,500 <br />Actual Loss <br /> <br />APPROVED AS TO FORM <br /> <br />Section 1I <br />L Busi""$:! lIaOility <br />M Meaical Paym.nlS <br />Products.Comp~ed Opmalioll$ <br />(PCQ) Aggregate <br />General Ag\lregale (Olll.., <br />Than I>CO) <br /> <br />i <br /> <br />1.000,000 <br />5,000 <br />2,000,000 <br />2,000,000 <br /> <br />DedUeUb~-Sectionl <br />$ 500 Basic <br /> <br /> <br />rill <br /> <br />Laura Still Shet <br />Assistant City Au rney <br /> <br />s <br /> <br />Forma, Options, and E.ndorsementl: <br />Spe~ Form 3 <br />. Addioonallnsured <br />Business POIi1;y Endorsamenl <br />Amenllalory Endorsemelll <br />Deb". Romov" E l1dorsemel'lt <br />POlicy EnoorSfment <br />GlaU Ceductible - Section I <br />. New Form ,,"achea <br /> <br />In Cll"'1 of lOss under !hili poli;y, the deduclibla wUl ."" <br />applied to tach ~1I(fenCQ .and Will be de6uellld from ,hg <br />amount of the I,,", Olhsr deductibles may apply. refer 10 <br />olic , <br /> <br />El'ldor811menl Premium Hone <br /> <br />FP-6143 <br />FE.8320 <br />FE -6484 <br />FE -6205 <br />FE -645 I <br />F!;.6506.2 <br />FE-6~38. , <br /> <br />Discounls Appliea: <br />Oaim Record <br /> <br />Preparfid <br />F~g 152005 <br />FP~80J02C <br />06/1993 <br />y~, poIfc;:o,. C;:9Nr.rs ul lfIIa _lie, oiInJ'.dol'&llmeftllS <br />and Ih. pn''''v 'om.. P~[ASt KEEP nlESI! TOGETH~R. <br /> <br />Comlnu(l(l on l'IeV6l$~ Side oJ Page <br />- OTH!;R LIMITS AND UCLUSIQIIII M^Y APPLY, R <br /> <br />Countersign"" <br />By <br />CIlECG CIiA~RD <br />f7U) n.~I1:1e1 <br /> <br />I-FAa <br /> <br /> <br />....!'Jt'l,~ <br /> <br />,...""'".... <br />(7""', <br /> <br />(.olt2:72b. <br /> <br />Prl'*,:nLi.:5A <br />