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APPENDIX D Sample Insurance Forms <br />(Continued) <br />Sample Certificate of Liability Form <br />aco,�o CERTIFICA E O, IABIL:ITY INSURANC 6R OATE,MMIDD "YI <br />. ...,RCO -1 11/12/97 <br />PRDGUCea THIS CERTIFICATE IS ISSUE OAS A MATTER OF INFORMATION <br />ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE <br />Insurance Services Group, Inc. HOLDER. THIS CERTIFICATEOOES NOT AMEND, EXTEND OR <br />204 Cedar Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, <br />Cambridge IM 21613 COMPANIES AFFORDING COVERAGE <br />G. Philip Pe Ldman COMPANY <br />410 - 228 -6464 1 -NU A Federal Insurance Company <br />INSURED <br />COMPANY <br />a <br />APR CONSULTING, INC. <br />Mr. Darryl Stone <br />COMPANY <br />22632 Golden Springs Dr. , .{330 <br />Diamond Bar CA 91765 <br />CDMPANY <br />p <br />THIS IS TO CERTIFYTHAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED, NOTWRHSTANDINO ANY REQUIREMENT, TERM OR CONDITION OF MY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO W HOH THIS <br />CERTIFICATE MAY BE ISSUED CR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBEO HEREIN IS SUBJECT TO ALL THE TERNS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POUCIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />Do <br />OR <br />TYPECFINSUR <NCE <br />PaLIOYNEASER <br />POUDYFFFECTIVE <br />DATEIMMO"Y) <br />PoUCYEMPIRATION <br />DATE(MMIDO.) <br />LM11TS <br />GEVEROLUARILIN <br />°ENERALAGGREGATE <br />$2,000,000 <br />A <br />X <br />OOMMERCMLOENERALLIABIUry <br />3532 -61 -16 CCG <br />04/01/97 <br />04/01/98 <br />PRCCUCTS- OOMPOPAGG <br />52 G00 000 <br />CLAIMEAACE X OCCUR <br />PERSONALSADVINJURY <br />S1,000,00G <br />EACH OCCURRENCE <br />51,000,000 <br />TX—C. CONTRACTOR'S PROT <br />A <br />X <br />Computer Software <br />3532 -61 -16 <br />04/01/97 <br />04/01/98 <br />FIRE DAMAGE(APy.. MP) <br />$Included <br />6 Syos ):60 <br />MED E%P 1.1nyDm panml <br />S 10,000 <br />g1,PE0,Dp06Ace, iPOi <br />AUTOm <br />° MLtt <br />ANAUTO <br />COMBINED SNGLE UNIT <br />S 1,000,000 <br />BODILY INyJRY <br />(PNpeNan) <br />f <br />ALLOWNEDMROS <br />Sg1EWLC- °AIRQS <br />A <br />X <br />X <br />HIREDAUTOS <br />NCWCWNEOAVTOG <br />3532 -61 -16 CCG <br />04/01/97 <br />04101/98 <br />RODIIXwNRv <br />(Pwami NJC0 <br />5 <br />PROPERTY DAMAGE <br />S <br />°ARAOEUMILITY <br />AUTOONLY- EAACCIOW <br />$ <br />ANYAUTO <br />OTHER TNN AVID ONLY: <br />EACH ACOOENT <br />S <br />AGGREGATE <br />S <br />EXCESSUA.L." <br />EALHOLCURRENCE <br />F <br />UMERELIA ' <br />AGGREDATE <br />f -- <br />OIHEfl THAN VMBRFLLA FORM <br />EMPLOYERS' LIABILITY AND <br />IMPLOYIM1S'UABILIYY <br />W <br />3T♦ <br />EL EACH ACCIDENT <br />L <br />THE <br />PARPNE VEXU.CU SILL <br />PAROERSARECUIIVE <br />EL DISEASE. PoLICY LIMIT <br />i <br />ELDISEASE�EAEMPLOYEE <br />S <br />OfflCERSAflE; IXCL <br />OTHER <br />DESCRIPTION OF DFERATIO NSILOCATONSNEHICLEL9PECIAL ITEMS <br />,:CANCELLATION ... <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES S ECANCELLID BEFORE THE <br />CITY OF SANTA ANA, ITS OFFICERS, AGENTS AND <br />EMPLOYEES <br />EXPIRATION DATE THEREDR THE ISSUING COMPANY VRLLRaREAAaRTa MAR <br />30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. <br />P.O. BOX 1988 <br />SANTA ANA. CA 92702 <br />MRHORDED REPRESENTATIVE <br />p <br />G Philip Hel dman P <br />ACORD 238; . , ,„. <br />t,0110 <ORP04AjIpf1;18 <br />Page 34 of 36 <br />