Insurance - Harper and Burns - 2011-07-06State Farm General Insurance Company
900 Old River Rd
Bakersfield, CA .93311-6000
AT1
R -23- 3601-F416 U 3
008209
JOHN R HARPER INC & JUDI
CURTIN & ALAN R BURNS &
CYNTHIA A BURNS(SEE FE 7315.1)
DBA HARPER & BURNS
453 S GLASSELL ST
ORANGE CA 92866 -1905
Location: 453 S GLASSELL
ORANGE CA
92866 -1905
SFPP No: 0367446623
Mortgagee: CITIZENS BUSINESS BANK
ITS SUCCESSORS AND /OR ASSIGNS
Loan No: 1595941525
orms, Options, and Endorsements
-'
,pecial Form 3
FP -6143
Valuable Paper $50,000
OPT VP
Emp Dishonesty $5,000
OPT ED
Amendatory Endorsement
FE -6205
Debris Removal Endorsement
FE -6451
Policy Endorsement
FE- 6506.2
Business Policy Endorsement.
FE -6464
Personal Injury Exclusion
FE -6346
Blank Endorsement
FE-7315.1
OH Premises Coverage
FE -6486
Glass Deductible - Section I
FE-6538.1
Lenders Loss Payable
438- BFU.NS
Continued on back of page
RENEWAL CERTIFICATE
POLICY NUMBER 92 65-69F,48
-'
Business- Office Policy
SEP 13 2011 to SEP 13 2012
BILLED THROUGH SFPP
Coverages and Limits
Section I
A Buildings
$418,700
B Business Personal Property
79, 000
C Loss of Income
Actual Loss
Deductibles - Section I
Basic
500
Other deductibles may
apply - refer to policy
Section 11
L Business Liability
$500,000
M Medical Payments
5,000
Gen Aggregate (Other than PCO)
1,000,000
Products - Completed Operations
1,000,000
(PCO Aggregate)
Annual Premium
$2,391.00
Forms, Opts, & Endrsmnt
64.00
Total Amount
$2,455.00
Premium Reductions
Renewal Year Discount
Yrs in Business Discount
Claim Record Discount
Cov. A - Inflation index: 208.2
Cov. B - Consumer Price: 226.0
NOTICE: Information concerning changes in your policy language is included. Please call your agent ii
you have any questions.
8
�, t4i S�i'vE Moving? See your State Farm agent.
(�"-- See reverse for important information.
N eoe, 401E Agent CHARLES W BOTT INS AGENCY INC Prepared
13 Telephone (949) 661.6272 REP JUL 06 2011
WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY O
INFORMATION PAGE
OLICY N0. 92- BV- CO48 -7 COVERAGE IS PROVIDED BY 23- 3601 -F416
REPLACES NO. 92- BP- N179 -0 STATE FARM FIRE AND CASUALTY COMPANY
900 OLD RIVER RD, BAKERSFIELD CA 93311 -6000
1. NAMED INSURED & MAILING ADDRESS
HARPER, JOHN (PTNR) & BURNY,
Q
ALAN TNR)
(DBA) HARPER & BURNS LLP
453 S GLASSELL ST
ORANGE CA 92866 -1905
NCCI CARRIER CODE NO. 14842
FEIN 953709217
LOCATION:
453 S GLASSELL ST
ORANGE CA 92866 -1905
INSURED IS LIMITED LIABILITY PTNRSHP
COPYRIGHT 1987 NATIONAL COUNCIL ON COMPENSATION INSURANCE
---------- -------------------------------------------------------------
2. THE POLICY PERIOD IS FROM 04/24/2011 TO 04/24/2012 12:01 A.M. STANDARD TIME
AT THE INSURED'S MAILING ADDRESS.
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3A. WORKERS COMPENSATION INSURANCE: PART ONE OF THE POLICY APPLIES TO THE
WORKERS COMPENSATION LAW OF THE STATES LISTED HERE: CA
B. EMPLOYERS LIABILITY INSURANCE: PART TWO OF THE POLICY APPLIES TO
WORK IN EACH STATE LISTED IN ITEM 3A. THE LIMITS OF OUR LIABILITY
UNDER PART TWO ARE: BODILY INJURY BY ACCIDENT $ 100,000 EACH ACCIDENT
BODILY INJURY BY DISEASE $ 100,000 EACH EMPLOYEE
C. OTHER STATES INSURANCE: PARTNTHREEBOFDTHEAPOLICY APPLIES TOLALL STATES
EXCEPT ME, MT, ND, OH, RI, WA, WV, WY AND STATES LISTED IN 3A.
D THIS POLICY THESE ENDORSEMENTS WC04010400WC040416
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4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF
RULES, CLASSIFICATIONS, RATES AND RATING PLANS. ALL INFORMATION
REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT.
-------------------------------------------------------------------------
CODE NOS. AND PREMIUM BASIS TO- RATE($100 ESTIMATED
CLASSIFICATIONS TAL ESTIMATED AN- REMUivvERA- ANNUAL
NUAL REMUNERATION TION PREMIUM
---------------------------------- - - - --- -------- --- -- - - -- --- - - - - -- --- - - - - --
8820 187,180 .93 1,741
ATTORNEYS - ALL EMPLOYEES - INCLUDING
SALESPERSONS AND CLERICAL OFFICE
EMPLOYEES- N.P.D.
TERRORISM 9740
187,180
03
W
MINIMUM PREMIUM $ 250 CALIFORNIA TOTAL ESTIMATED ANNUAL'PREMIUM $' 1,797
----------------- - - - - --
---- ------- - -----
EMIUM ADJUSTMENT PERIOD SHALL BE ANNUAL DEPOSIT - - -----
PREMIUM $ 1,797
STATE FRAUD SURCHARGE $ 8.00
PREPARED 02/15/2011 COUNTERSIGNED OVERFLOW PAGE
WC 00 00 01 04 -84 +_X 80 2286 6621 BY AGENT