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BINDER-RECEIPT <br />"?""'"'" ? STATE FARM FIRE AND CASUALTY COMPANY <br />® STATE FARM GENERAL INSURANCE COMPANY <br />rMYeANti F1 STATE FARM FLORIDA INSURANCE COMPANY <br />[] STATE FARM LLOYDS <br />? Apartment ® Business <br />Rental Dwelling ? Church <br />? Condominium Association ? Other <br />..,,..r Y - <br />I Name LAW ENFORCEMENT MENTAL HEALTH SOLUTIONS Effective <br />Date: 03-054012 <br />FM Name Middle Name or Iddal <br />co-epp1cows Name (x app fa"e) <br /> D/B/A <br />Mailing Numnerandsmaet atyorTmn <br />address 4630 CAMPUS DR STE 110 NEWPORT BEACH <br />state ZIP Cade <br />CA County <br />926604804 <br />POLICY/COVERAGE INSURANCE PROPERTY OR LOCATION AND DESCRIPTION OF <br />FORM LIMITS INTERESTS COVERED PROPERTY OR INTERESTS PREMIUM <br />Liability: <br />? Business Liability earn <br />NOTE: The Annual Aggregate and <br />PmduMkompbted opemdom <br />eWrogate ernlts are equal to 2 <br />fifes tie oecumerma IBNL <br /> <br />? Personal Liability acn fence <br /> <br />7717- <br /> <br />? Medical Payments Each pemm <br /> <br /> <br />Deductibles: 1000 Total Premium $ 673 <br /> <br />Name and Address of Mortgagee/Other Interest: ---------------------- ----------------------- <br /> Amount Paid $ 0.00 <br />Named Additional Insured,City of Santa Ana,20 Civic Center PIa,Santa Ana, Loan Number: <br />CA,927014058 <br />State Farm6 will provide coverage to the applicant and his or her legal representative on the property described for up to ninety (90) <br />days from the Effective Date, subject to all terms and conditions of the policy and endorsements for which application has been made. If <br />no Effective Date is indicated, this Binder does not provide any coverage. This Binder will be void when the declarations page is issued <br />on the policy for which application has been made or when coverage under this Binder is canceled In accordance with policy provisions. <br />The premium due State Farm for the coverage provided by this Binder will be the full annual premium for the policy for which <br />application has been made, and will be pro-rated for the length of time coverage is provided under this Binder. <br />If coverage in this Binder replaces coverage in other policies terminating at 12 Noon Agent's Code Stamp <br />(Standard Time) on the inception date of this Binder, this Binder will be effective at 12 Charione Hatakeyams F <br />Noon (Standard Time) instead of 12:01 a.m. Standard Time. 7811 Valley View St <br />La Polma,CA,90623-1849 <br />(714)5274897 <br />AGENT: It is very important that you mail a copy of the Binder and a completed application to this Company on the day issued <br />53"30b Rev.W22.2o05 1003667 2004 141208 204 12-21,21)11