PROOF OF INSURANCE (2005) CLOSED06/29/04 VON 1$ :29 FAX 714 050 2904 KsC ISS ®001
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jj•d L69fr -2LL -908 uI suedwoo 9 eMsnueW uoa WUBT(E 0002 So qaj
Policy Number
90 -CD- 7668 -4
DECLARATIONS PAGE AMENDED JUN 30 2004
STATE FARM GENERAL INSURANCE COMPANY
900 OLD RIVER RD, BAKERSFIELD CA 93311 -6000
A STOCK COMPANY WITH HOME OFFICES IN BLOOMINGTON, ILLINOIS
1849 -F781 T
BUSINESS POLICY - SPECIAL FORM 3
Named Insured and Mailing Address
MARUSKA, DONALD & COMPANY INC
DBA NOVAQUEST
DBA DECISON SUPPORT NETWORK
DBA COACH EXPRESS
895 NAPA AVE STE A5
MORRO BAY CA 93442 -1945
Cov A - Inflation Coverage Index: N/A
Cov B - Consumer Price-Index: 188.0
AUTOMATIC RENEWAL - If the POLICY PERIOD is shown as 12 MONTHS, this policy will be renewed, automatically
subject to the premiums, rules and forms in effect for each succeedin policy period. If this policy is terminated, we wits
give you and the Mortgagee /Lienholder written notice in compliance wi h the policy provisions or as required by law.
Policy Period: 12 Months The policy period begins and ends at 12:01 am standard time at the
Effective Date: AUG 16 2004 premises location.
Expiration Date: AUG 16 2005
nsu
Location of Covered Premises:
895 NAPA AVE STE A5
MORRO BAY CA 93442 -1945
Coverages & Property
Section I
A Buildings
B Business Personal Property
C Loss of Income - 12 Months
Section II
L Business Liability
M Medical Payments
Products - Completed Operations
(PCO) Aggregate
General Aggregate (Other
Than PCO)
Limits of Insurance
Excluded
19,600
Actual Loss
$ 1,000,000
$ 10,000
Excluded
$ 2,000,000
Forms Options, and Endorsements
Special Form 3
FP -6143
'Additional Insured
FE -6320
Business Policy Endorsement
FE -6464
Amendatory Endorsement
FE -6205
Tree Debris Removal
FE -6451
Policy Endorsement
FE- 6506.2
Personal Injury Exclusion
FE -6346
• New Form Attached
Your policy is amended JUN 30 2004
ADDL INSURED NAME & ADDRESS CHANGED
ENDORSEMENT FE -6320 ADDED
Other items shown are effective
with the Dolicv's 2004 renewal
ccupancy: uttice
Deductibles - Section I
$ 250 Basic
In case of loss under this policy: the deductible will be
applied to each occurrence and will be deducted from the
amount of the loss. Other deductibles may apply - refer to
Endorsement Premium None
Discounts Applied:
Renewal Year
Years in Business
Claim Record
Continued on Reverse Side of Page
OTHER LIMITS AND EXCLUSIONS MAY APPLY - REFER
Prepared
JUN 30 2004 Countersigned_
FP- 8030.2C 12N5 By -As'��
06/1993 KAREN PERLETfE /
Your policy consists of this page, any endorsements (805) 772 -7363
and the policy form. PLEASE KEEP THESE TOGETHER.
YOUR
Agent
(02172b)
Policy Number
90 -CD- 7668 -4
CONTINUED FROM FRONT SIDE
BUSINESS POLICY - SPECIAL FORM 3
Forms,Opptions,and Endorsements
Additional Insured Endorsement FE -6494
Advertising Injury Excl FE -6345
Glass Deductible - Sect I FE- 6538.1
Testing /Consulting E &O Excl FE -6510
Products /Operations Liab Excl FE -6312
Amendatory Collapse FE -6551
Terrorism Insurance Cov Notice FE -6999
IMPORTANT NOTICE:
California law requires us to provide you with information for filing complaints with the State Insurance
Department regarding the coverage and service provided under this policy.
Complaints should be filed only after you and State Farm or your agent or other company representative
have failed to reach a satisfactory agreement on a problem.
Please forward such complaints to:
Prepared
JUN 30 2004
California Department of Insurance
Consumer Services Division
300 South Spring Street
Los Angeles, CA 90013
Or call toll free: 1- 800 - 927 -HELP
GE
(oV2176c) (02175a)
.fr ' SH Policy No. 90 -CD- 7668 -4 EFFECTIVE JUNE 30 2004
ADDITIONAL INSURED ENDORSEMENT
DESIGNATED PREMISES ONLY
Policy No.: 90 -CD- 7668 -4
Named Insured: MARUSKA, DONALD & COMPANY INC
Name of Additional Insured: CITY of EL SEGUNDO
Address of Additional Insured: CITY CLERKS OFFICE
350 MAIN ST RM 5
EL SEGUNDO CA 90245 -3813
Interest of Additional Insured: CONTRACTOR OF SERVICES
Location of Premises: PER CONTRACT
FE -8320
(7/88)
liAlt IAtM
INtY I�NtI@
The word "insured ", wherever used in this policy, also includes the designated person or organization named above
as Additional Insured under the provisions of the policy Sections shown below as applicable by an "X" to the extent
indicated.
❑ SECTION I. This applies only to COVERAGE A - BUILDINGS.
❑ SECTION I. This applies only to COVERAGE B - BUSINESS PERSONAL PROPERTY.
Description of Property:
M SECTION II. This applies only to COVERAGE L - BUSINESS LIABILITY and COVERAGE M -
MEDICAL PAYMENTS and then only with respect to the ownership, maintenance or use of
the premises designated above and operations necessary or incidental thereto. These
SECTION II coverages do not apply to:
1. structural alterations or new construction performed by or on behalf of the designated person or
organization;
2. personal injury caused by the designated person or organization;
3. liability the designated person or organization assumed under a contract; or
4. products - completed operations hazard arising out of goods or inventory which are not sold or
distributed by you or arising out of the manufacturing or packaging of such goods or inventory.
All other provisions of the policy apply.
FE -8320
(7/88)
Printed in U.S.A.