PROOF OF INSURANCE (2009) CLOSED (2)52 This Spectrum Policy consists of the Declarations, Coverage Forms, Common Policy Conditions and any
36 other Forms and Endorsements issued to be a part of the Policy. This insurance is provided by the stock
Ax insurance company of The Hartford Insurance Group shown below.
SBM
INSURER: HARTFORD CASUALTY INSURANCE COMPANY
HARTFORD PLAZA, HARTFORD, CT 06115
COMPANY CODE: 3 my
Policy Number: 72 SBM AH3652 DX
SPECTRUM POLICY DECLARATIONS COPY
o Named Insured and Mailing Address: ELLA SOTELO
o (No., Street, Town, State, Zip Code)
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2202 ROBRUCE LANE '
HACIENDA HEIGHT CA 91745
0 Policy Period: From 11/07/08 To 11/07/09 : 1 YEAR
0 12:01 a.m., Standard time at your mailing address shown above. Exception: 12 noon In New Hampshire.
o Name of Agent/Broker: KTL BUSINESS INS SRVCS, INC /PHS
Code: 165446
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o Previous Policy Number: 72 SBM AH3652
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ro Named Insured is: INDIVIDUAL
Audit Period: NON - AUDITABLE
Type of Property Coverage: NONE
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Insurance Provided: In return for the payment of the premium and subject to all of the terms of this policy, we
agree with you to provide insurance as stated in this policy.
TOTAL ANNUAL PREMIUM IS: $350 MP
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Countersigned by 08/26/08
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Authorized Representative Date
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Form SS 00 0212 06 Page 001 (CONTINUED ON NEXT PAGE)
Process Date: 08/26/08 Policy Expiration Date: 11/07/09
UW COPY
SPECTRUM POLICY DECLARATIONS (Continued)
POLICY NUMBER: 72 SBM AH3652
Location(s), Building(s), Business of Named Insured and Schedule of Coverages fonPremises as designated by
Number below.
Location: 001 Building: 001
2202 ROBRUCE LANE
HACIENDA HEIGHTS CA 91745
Description of Business:
CONSULTANT - NOC
Deductible: NO COVERAGE
BUILDING AND BUSINESS PERSONAL PROPERTY LIMITS OF INSURANCE
BUILDING
BUSINESS PERSONAL PROPERTY
REPLACEMENT COST
PERSONAL PROPERTY OF OTHERS
REPLACEMENT COST
MONEY AND SECURITIES
INSIDE THE PREMISES
OUTSIDE THE PREMISES
Form SS 00 0212 06
Process Date: 08/26/08
NO COVERAGE
NO COVERAGE
NO COVERAGE
NO COVERAGE
NO COVERAGE
page 002 (CONTINUED ON NEXT PAGE)
Policy Expiration Date: 11/07/09
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SPECTRUM POLICY DECLARATIONS (Continued)
POLICY NUMBER: 72 SBM AH3652
BUSINESS LIABILITY
LIMITS OF INSURANCE
LIABILITY AND MEDICAL EXPENSES
$1,000,000
MEDICAL EXPENSES -ANY ONE PERSON
$ 10,000
PERSONAL AND ADVERTISING INJURY
$1,000,000
DAMAGES TO PREMISES RENTED TO YOU
$ 300,000
ANY ONE PREMISES
AGGREGATE LIMITS
PRODUCTS - COMPLETED OPERATIONS
$2,000,000
FORM SS 05 09
GENERAL AGGREGATE
$2,000,000
Form SS 00 0212 06
Process Date: 08/26/08
Page 003 (CONTINUED ON NEXT PAGE)
Policy Expiration Date: 11/07/09
SPECTRUM POLICY DECLARATIONS (Continued)
POLICY NUMBER: 72 SBM AH3652
Form Numbers of Forms and Endorsements that apply:
SS 00 01 04 93 SS 00 05 12 06 SS 00 08 04 05
SS 01 21 08 97 SS 05 09 07 00 SS 05 47 09 01
SS 83 76 01 08
SS 00 45 12 06
SS 50 19 01 08
Form SS 00 0212 06 Page 004
Process Date: 08/26/08 Policy Expiration Date: 11/07/09
SPECTRUM POLICY DECLARATIONS (Continued)
POLICY NUMBER: 72 SBM AH3652
SUPPLEMENTAL DECLARATIONS:
A service fee of $ 0007.00 is charged for each installment when your premium is paid in
installments. The service fee is $ 0005. oo per withdrawal when you select an electronic
fund transfer payment plan. The service fee will be added to the premium-.amount
N shown on your premium billing statement.
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Form SS 00 4512 06
Process Date: 08/26/08 Policy Expiration Date: 11/07/09