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<br />07/25/2005 02:41 <br /> <br />7145445730 <br /> <br />LATOURETTE STATE FAR <br /> <br />CERTIFICATE OF INSURANCE <br />o STATE FARM FIRE AND CASUALTY COMPANY, Bloomington,lIIlnois <br />181 STATE FARM GENERAL INSURANCE COMPANY, Bloomington. Illinois <br />o STATE FARM FIRE AND CASUALTY COMPANY. Scarborough. Ontario <br />o STATE FARM FLORIDA INSURANCE COMPANY. Wlntar Haven, Florida <br />o STATE FARM LLOYDS, Dallas. TeXas <br />insures the following policyholder for tha coverages indicated below: <br />Policyholder John campbell, DM Benefit FUnding Service Group <br /> <br />OU" .... <br />A <br />,...,..-.., <br /> <br />This certifies lhal <br /> <br />Address of pOllcyholdar <br />loC:8tion of operations <br />DescriptIon of operations <br /> <br />2040 Main Street. Ste 150, rrvine, CA 926J.4 <br /> <br />PAGE 01 <br /> <br />The policias listed below h.ve been issued to the policyholder for the policy periods shown. The insurance described in lhese policies is <br />subjecllo all the tarms exclusions and cond~ions of those policies The Iim~ of liability shown may h.ve been reduced by any paid claims. <br /> <br /> POLICY PERIOD LIMITS OF LIABILITY <br />POLICY NUMBER TYPE OF INSURANCE Effe<:tive Dale ; E>qlInotlon Da1lo [at b9ginnlng 01 policy period) <br />92-YG-4106 2 G Comprehansill8 7/0B/05 , 7/08/06 BODILY INJURY AND <br /> .Bu.'..i~.~~~.Liabil!\}'. ........ .m____.....__..L h......__ __..... PROPERTY DAMAGE <br />. Thi"s insumnce- i~ci~des:. . o ProduclS . Completed Operations <br /> o Contractual Liability Each Occorrenoe p, 000, 000 <br /> o Personal InJury <br /> o Adll8rtising Injury General Aggregate $ ',000,000 <br /> 0 <br /> 0 Products - Compieled $101,900 <br /> 0 Ooaratlons Aaaregate <br /> POLICY PERIOD BOOIL Y INJURY AND PROPERTY DAMAGE <br /> EXCESS LIABILITY Effective Data : EllDlr.otion Dale (Combined Single Li",~) <br /> o Umbrella : Each Occurrence $ 5000 <br /> o Other Aggregate $ <br /> POLICY PERIOD Part I - Workers Compensation . Slalutory <br /> Effectl.... Dam : Explr.rtlon Dale <br /> Workers' Compensation : Part II - Employers Liability <br /> and Employers Liabiiity i Each Accident $ <br /> Disa..... Each Employea $ <br /> Diseass - Policy Umil $ <br /> POLICY PERIOD LIMITS OF LIABILITY <br />POLICY NUMBER TYPE OF INSURANCE Et'factlve Dale : E>qlInotlon Dale (at beginning 01 policy period) <br /> : <br /> : <br /> : <br /> <br />THE CERTIFICATE OF INSURANCE 18 NOT A CONTRACT OF INSURANCE AND NEITHER AFFIRMATIVELY NOR NEGATIVELY <br />AMENDS, EXTENDS OR ALTERS THE COVERAGE APPROVED BV ANY POLICY DESCRIBED HEREIN. <br /> <br />Name and Address of Certificate Holder <br /> <br />(Addi tional ;r:n3u.red) <br />City of Santa Ana <br />20 Civic Center. Plaza <br />Santa Ana, CA 92701 <br /> <br />." A" TO FORlvI <br />1~.Ct\.1 t~l) t~;:-' <br /> <br /><II / ') <br />7/?\,(:,'_{.-.{1 ,." I --- <br /> <br />'/ ." ".-.-- . "./" --'('lly <br />'. .~ ~ . <br />/,\ "IC\' <br /> <br />6SS..g94 a.S R~ 1'-0e..;z00t Printed In V.SA <br /> <br />If any of the described polloie. ara canceled befo", <br />Iheir ""plration date, Slate Farm will Iry 10 mail a <br />wrfften nolice 10 the certificate holder 30 days before <br />cancellation. If however. we fail to mail such notica, <br />no obligation or Ii bllity will be Imposed on State <br />Fa its a en or re resentativ <br /> <br /> <br />SIgnature of Authortz::ed Representetwe <br />AGENT <br />nl. <br />I<en L.... Tour.ette <br />~ent Narne <br />TBI.pnaneNumbef ;14/541-]779 <br /> <br />Ager1t',s Code $tsmp <br />Agent Code 8 906 <br />AFO Cod. F418 <br /> <br />7125105 <br />Dam <br />