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<br />Page 1 of I <br /> <br />Certificate of Insurance <br />Sparta Program <br /> <br />Name Insured: <br />Achatz, Danie J <br />4390 Monte Verde <br />Pomona. CA 91766 <br /> <br />Certificate # <br />Coverage <br /> <br />Limits <br /> <br />Deductibles <br /> <br />Terms & <br />Couditions <br /> <br />Exclusions <br /> <br />SSA06-0038 <br /> <br />Named Additional Insured: <br />SANTA ANA (SPARTA) ! <br />20 Civic Center Plaza PO Box 1988,111~ ,zO();2. OJ( <br />Santa Ana CA 92701 AI" ~ ;200.2- 0)(8 - 0/ <br />N - ~O 0). ~ O).{! ~O:? <br /> <br />N~ ,j(XJ~_ OJ(~ - 0::' <br /> <br />SPARTA INSURANCE PROGRAM: Commercial General Liability - Hazard 2 <br />Contract Value: S9,500.OO <br />Coverage Period: 5/22/2007 to 5/22/2008 <br />Insurance Carrier: Essex Insurance Company <br />Master Policy: 3CV8902 <br />Master Policy Effective Date: 11/15/2006 to expiration <br /> <br />$2,000,000 General Aggregate I $1,000.000 Each OCCurrence / $1,000,000 Products/Completed operations <br />$1,000,000 Personal & Advertising Injury/S50,OOO Fire Damage / Medical Payments Excluded <br /> <br />$500 BI & PD Per Claimant Including Loss Adjustment Expense <br /> <br />$450.00 Premium (Fully Earned) <br />$14.29 Taxes (Fully Earned) <br />$50.00 Certificate Fee (Fully Earned) <br /> <br />$514.29 Total Amount <br /> <br />I. No Cancellations Allowed. Premium, taxes and fees are fully eamed at inception. <br />2. Operations and Rating Based: Instructional services for inmates related to anger management, stress reduction, <br />domestic violence. LESS THAN (30) ACTUAL WORKING DAYS. <br />3. Department: Not Applicable <br />4. Additional Insured(s): Not Applicable <br />5. No Professional Liability Coverage provided. <br /> <br />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 po [icy is limited to your work perfonned on hehalf of the entity named as <br />"Additional Named Insured" above and doesn't extend itself [0 any other work perfonned 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 /> <br />Per the Master policy, a copy is available by written request to: Municipality Insurance Services, Inc., 302 W. <br />Cerritos Ave., Building #7, Anaheim, CA 92805 <br /> <br />~. <br /> <br />"'.".;. \.. ,;/ <br /> <br />,..,"'(',,~ -:'>~ <br /> <br />-"--~~:,~~/ <br /> <br />Carol Frost I President <br />Municipality Insurance Services, Inc. <br /> <br />'""H"'IL''''''~'''".(-- ,.- <br />n I..., 'U ~'f1 J:15 PUR <br /> <br />302 W. Cerritos Ave Bldg# 7 Anaheim, CA 92805 (800) 420-ll555 (714) 687-1100 fax (714) 687-1106 LicensesCA:OC04849; OR: 195423 <br />Website address www.2sparta.com <br />