HENNESSEY & HENNESSEY INC. 1 - 2005

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COMPANY NAME: MID-CENTURY INSURANCE COMPANY, LOS ANGELES, CALIFORNIA A STOCK INSURANCE COMPANY, HEREIN CALLED THE COMPANY PART I CERTIFICATE OF INSURANCE INSURED's NARIS & ADDRESS: SHARON A H LA BONTE 17962 WESTON PL TUSTIN CA 92780 ISSUING OFFICE: P. O. BOX 4820 POCATELLO, ID 83205 DESCRIPTION OF VEHICLE MI.-I-4 "n-1.1 POLICY NO: 97 17615-29-63 -/I - p200 POLICY EDITION: 02 /`t EFFECTIVE DATE: 08-08-2007 EVIRATION DATE: - O NI'INT NMS I INTIL CANCELLED EXPIRATION TIME: 12:01 A.M. Standard Time AGENT: Tyler Harms AGENTNO: 97 44 31L AGENT PHONE: (714) 744-0733 Yea Make Madd' Ve" Iden ifitdon Number 2002 BMW 530I WBADT63462CK25841 COVERAGES * ENTRIES IN THOUSANDS OF DOLLARS. (SEE REVERSE SIDE FOR COVERAGE DESIGNATIONS) Bodily Ilay P.D.Iowhrg Etnhure Motorist pdtpom Me • Compre ernive Co inion Ivry Ecru n�rerrt__ no Fault Dedudlik Deductible— — Hm-Auto * 250 500 100 250 1 500 11COV 1000 5.000 1000 1000 NOT COV ---fly ---- NC 1 NC Each 1 Each Each Each hob. Medical Person ! c urr n e Person c rre e COV This certificate is subject to all of the terms, conditions and limitations set forth in the policy(ies) and endorsements attached to it. It is furnished as a matter of inforniation only and does not change, modify or extend the policy in any way. It supersedes all previously issued certificates. PART II ADDITIONAL INSURED ENDORSEMENT E 1 136 3rd Edition We provide the coverages indicated by "COV," or the limit of the Company's liability, on the above Certificate of Insurance. We provide this coverage in respect to the vehicle described above, to the person or organization named below as an additional insured. This coverage applies only: (1) while the named insured is the owner, or has care, custody, or control of the above described vehicle, and (2) when liability arises out of the acts and omissions of die named insured. 'I'lhis coverage does not apply: (1) where liability arises out of negligence of the additional insured, its agents, or employees, unless the agent or employee is the named insured, or (2) to any defect of material, design or workmanship in any equipment of which the additional insured is the owner, lessor, manufacturer, mortgagee, or beneficiary. If any court shall interpret dhis endorsement to provide covenige other than what is stated in the Certificate of Insurance, then our limits of liability shall be die. limits of bodily injury liability and property damage liability specified by any motor vehicle financial responsibility law of the state, province, or territory where tie named insured resides, as applicable to the vehicle described above. If there is no such law, our limit of liability shall be $5,000 on account of bodily injury sustained by one person in any one occurrence and subject to this provision respecting each person, $10,000 on account of bodily injury sustained by two or more persons in any one occurrence. Our total liability for all damages because of all property damage sustained by one or more persons or organizations as the result of any one occurrence shall not exceed $5,000. The insurance afforded by the policy described above is subject to all terms of the policy and any endorsements attached to it. This endorsement dues not increase the limits of the policy. Upon cancellation or termination of this policy or policies from any cause we will mail 15 days notice in writing to the other interest shown below. CITY OF SANTA ANA ` 20 CVIC PZ M36 CA SANTA ANA CA 92702 AUTHORIZED SIGN l FZE 91-1136 3RD EDITION 1-05 11136331 0�b