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APPENDIX D Sample Insurance Forms <br />(Continued) <br />Sample Certificate of Liability Form <br /> aco.~o CERTIFICATE OF LIABI LITY INSURANC~R~' °ATE,MMIO°~, <br /> RCO-1 11/12/97 <br /> PaocuceR THIS CERTIFICATE IS ISSUED A6 A MATTER OF INFORMATION <br /> ONLY AND CONFERS ND RIGHTS UPON THE CERTIFICATE <br /> Insurance Services Greup, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR <br /> 204 Cedar Stree! ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, <br /> Cambridge PID 21613 COMPANIES AFFORDING COVERAGE <br /> G. Philip Feldman coMPANr <br /> PnenA N•. 410-2 S-fi464 Fu xo. A Federal Insurance Comgaany <br /> INSURm ppMPAM• <br /> B <br /> APR CON9VLTING, INC. wMPAN1 <br /> Hr. Darryl Stone C _ <br /> <br />22632 Golden Bpzinga Dr., .11330 _ <br /> <br />Diamond Har CA 91765 ~ OGMPANY <br />p <br /> COVERAGES <br /> THIS IS TO CERTFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN 63UED TO THE NJSURED NAMED ABOVE FOR THE POLICY PERIOD <br /> INDICATED, NOTWRHSTANDING ANY REW IREMENT. TERM OR LONDmON OF ANV CONTRACT OR OTHER DOCUMENT WITH RESPECT TO W HIGH THIS <br /> CERTIFICATE IMY BE ISSUED OR MAY PERTNN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 13 SUBJECT TO ALL THE TERMS, <br /> E%CLUSIONS AND CONDITIONS OF BUCH POLICIES. OMITS SXOWN MAY IUVE BEEN REDUCED BY PND GUMS. <br /> CO <br />LTR TYPE OG INSVRµIC¢ PoLICY NUMaFJI POLICY EFFECTNE <br />OATS IMMTWYTI PIXICY E%PIPATION <br />OATS IMMIOONI'I LIMITS <br /> GE NERAL 4nBILITY GENERµ AGGREWTE f2, 0DD D00 <br /> A X cGMMERCML GENERAL UABILm 3532-61-16 CCG 04/01/97 04/01/93 PRODUCTS-wNPNPAw s2 000 000 <br /> CLAIMS AU°E OOCNR PERSONALS AOV INIJRY f 1 a0o,oo0 <br /> °WI.ER96 CONRiALTORB PROT EALN wCURRENCE f 1, DDD,DDO <br /> A X Coalputer 9oftrFara 3532-61-16 04/01/97 04/01/98 FIRE DAMAGE P.nY^^•Rr•I sIRCluded <br /> L Svcs E60 #,009,009 a.ATfe MAO9 MEO EN pnr a•P•~•••1 s 10 000 <br /> AVT GYOdLE LIABILItt <br /> COMSINE0911.'OLE LRA? f 1,DDD, DDO <br /> ANY AUTO <br /> ALL O'NNEp AUIw BCIX.r WJURY <br /> SOIEOVLEO AIrt05 IPN P•~•••1 S <br /> A X HIRm AUros 3532-61-16 CCG 04/01/97 O9/Ol/9B <br /> $wrtr wJU3r <br />f <br /> X NONGWNm AUTOS PN •ck•nR <br /> <br /> MiOPERN DAMAGE f <br /> GARAGE LPOILRY AUTO ONLr ~EA ACCDENT f <br /> µIYAVTO OTXfRiW.N AIROONLY. <br /> EAGI ACCIDENT f <br /> AGGREGATE f <br /> E1CES9 q/HILITY EACH OCCURRENCE f <br /> VMBREIU FORM AGGREGATE f <br /> OTTER TV.H UM&iELLAFORM 9 <br /> N'ORNERS COMPENSATION AHO <br />' I WC ATl OTH <br />TORY LIMBS ER <br /> EMPLOYERS <br />LMMLRY EL EACH ACCHIENT f <br /> THE PRCPRIETgU <br />PARINERSECECUTNE INCL EL g3EA5E~G\YnY UMR f <br /> CiFICERB ARE'. ENCL EL gBEASE~FA EMMOYFE f <br /> OTHER <br /> OESCRIPT°N OF OPEMTION9M1wATON9NEHICLESISPECIAL ITEMS <br /> CERTIFICATE.HOLOER` _ CANCELLATION _ <br /> SHOULD NIY°F THE ABOVI OESCRIBEOPttIdES BE CAMCELLE°BEFORE THE <br /> CITY OF SANTA ANA ITS OFFICERS. AGENTS AND ERnIUnGH OATe TH¢RmF, THE USwaa COMPANY wlucw•e1wIFw MAIL <br /> <br />EMPLOYEES 3U DAYS NTmIX HOTK.E iD THE CETTIFICATE HOLDER XAMED IDTHE LEFT, <br /> P.O. BOX 1)88 <br /> SANTA ANA CA')2702 <br /> AUTNORREO REPRESENL1iIVE <br /> G. Philip Pe1~Lan / / <br /> ACORD 29S (1794( ` ` OACORD CORPORATIONY938 <br /> <br />Page 32 of 34 <br />