Insurance - Kasprzyk, Theresa R. - 2016-06-28AC40RD CERTIFICATE OF LIABILITY INSURANCE OATEIMMIDONrM
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THIS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE. HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: It the certificate holder Is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder In lieu of such endorsement(s).
PRODUCER
StateFarm STATE FARM INSURANCE
'® MARK R REESE, AGENT
®i 8730 NICFAODEN AVE SUITE 205
WESTMINSTER; CA 92683
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(ACHE 714.695 3022 - FAX _ -
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INSURERA � State Farm Generai Insurance Company 25151
INSURED _.. _ __ _.._ ......__...
jNS1IRER e._.,.__..-_.
THERESA KASPRZYK INSURERc: __ _
DBA TERRASTAR MEDIA_ -- --
INSDRER D:
13861 JASPERSON WAY INSLJREREL
WESTMINSTER, CA 92683 - __- ____........._
INSUR€RP:
CnVFRACFS CFRTIFICATF NIIMRFR- VF -QIruu minifiRFR.
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED. BELOVI HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANOING ANY REOUIREMENt. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT AITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES- LIMITS SHOWN MAYHAVE BEEN REDUCED BYPAID CLAIMS,
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DESCRIPTION OF OPERATIONS! LOCATIONS lOENICLES (ACORO 101, A"Ilanal Ramada Scedule, may be AlllEfied it MOM Space Is faqulmdl
The Costa Mesa Sanitary District. its elected and appointed
officials,agents.otfcers.volunteers and employees are additional
Insureds,
628 w 19th St, Costa Mesa CA 92627
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE VATH THE POLICY PROVISIONS.
SAY
4TION. All rights reserved.
ACORD 25 (2016103( The ACORD name and logo are registered marks of ACORD
IO i14M 137312.12 U? -162:15
State Farm 92 -CF -N648-5 016660
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•
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY,
CMP4786.1 ADDITIONAL INSURED — OWNERS, LESSEES, OR CONTRACTORS
(Scheduled)
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS COVERAGE FORM
SCHEDULE
Policy Number: 92 -CF -N648-5
Named Insured:
KASPRZYK.THERESA
DBA TERRASTAR MEDIA
13861 JASPERSON WAY
WESTMINSTER CA 92683-4012
Name And Address Of Additional Insured Person Or Organization:
CMP -4786.1
Page 1 of 2
THE COSTA MESA SANITARY DISTRICT ITS ELECTED & APPOINTED OFFICIALS AGENTS OFFICERS V
OLUNTEERS & EMPLOYEES
628 W 19TH ST
COSTA MESA CA 92627-2716
SECTION II — WHO IS AN INSURED of
SECTION 11 — LIABILITY is amended to in-
clude, as an additional insured, any person or
organization shown in the Schedule, but only
With respect to liability for "bodily injury",
"property damage", or "personal and advertis-
ing injury" caused, in whole or in part, by:
a. Ongoing Operations
(1) Your acts or omissions; or
(2) The acts or omissions of those acting
on your behalf;
in the performance of your ongoing opera-
tions for that additional insured; or
b. Products – Completed Operations
"Your work" performed for that additional
insured and included in the "products -
completed operations hazard
However, Paragraph 1. above is subject to the
following:
a. The insurance afforded to the additional
insured only applies to the extent permit-
ted by law;
b. If coverage provided to the additional in-
sured is required by a contract or agree-
ment, the insurance provided to the
additional insured will not be broader than
that which you are required by the contract
or agreement to provide for such addition-
al insured; and
c. If the contract or agreement between you
and the additional insured is governed by
California Civil Code Section 2782 or
2782,05, the insurance provided to the
additional insured is the lesser of that
which:
(1) Is allowed for the satisfaction of a de-
fense or indemnity obligation by Cali-
fornia Civil Code Section 2782 or
2782.05 for your sole liability; or
(2) You are required by contract or
agreement to provide for such addi-
tional insured.
We have no duty to defend or indemnify the
additional insured under this endorsement un-
til a claim or "suit" is tendered to us.
®, Copyright, State Farm Mutual Automobile Insurance Company, 2013
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
CONTINUED
Office Policy for KASPRZYK THERESA
Policy Number 92 -CP N848-5
COVERAGE
LIMIT OF
INSURANCE
Coverage L - Business Liability
$1,000,000
Coverage M - Medical Expenses (Any One Person)
$5,000
Damage To Premises Rented To You
$300,000
AGGREGATE LIMITS
LIMIT OF
INSURANCE
Products/Completed Operations Aggregate
$2,000,000
General Aggregate
$2,000,000
Each paid claim for Liability Coverage reduces the amount of insurance we provide during the applicable
annual period. Please refer to Section II - Liability in the Coverage Form and any attached endorsements.
Your policy consists of these Declarations, the BUSINESSOWNERS COVERAGE FORM shown below, and any other
forms and endorsements that apply, including those shown below as well as those issued subsequent to the
issuance of this policy.
CMP -4101
Businessowners Coverage Form
FE -6999.2
'Terrorism Insurance Cov Notice
CMP -4786.1
Addl Insd Owners Lessee Sched
CMP -4819.1
Unauthorized Business Card Use
CMP -4698
Back -Up of Sewer or Drain
CMP -4704
Dependent Prop Loss of Income
CMP -4710
Employee Dishonesty
CMP -4709
Money and Securities
CMP -4703
Utility Interruption Loss Incm
CMP -4705.1
Loss of Income & Extra Expnse
FD -6007
Inland Marine Attach Dec
New Form Attached
Prepared
MAY 10 2016 T Copyright, State Farm Mutual Automobile Insurance Company, 2008
CMP -4000 Includes copyrighted material of Insurance Services office, Inc., with its permission.
016461 294 Continued on Reverse Side of Page
E
Page 5 of 7
Office Policy for KASPRZYK THERESA
Policy Number 92 -OF' -N648-5
SCHEDULE F OF ADDITIONAL INTERESTS
Interest Type: Add[ Insured -Section II
Endorsement #: CMP47861
Loan Number: N/A
COSTA MESA SANITARY DISTRICT
ITS DIRECTORS OFFICIALS
OFFICERS EMPLOYEES AGENTS &
VOLUNTEERS
628 W 19TH ST
COSTA MESA CA 926272716
Interest Type: Addl Insured -Section 11
Endorsement #: CMP47861
Loan Number: N/A
MIDWAY CITY SANITARY
DISTRICT, ITS DIRECTORS,
OFFICERS, EMPLOYEES, AGENTS &
VOLUNTEERS
14451 CEDARWOOD ST
WESTMINSTER CA 926835390
This policy is issued by the State Farm General Insurance Company.
Participating Policy
You are entitled to participate in a distribution of the earnings of the company as determined by our Board of Directors in
accordance with the Company's Articles of Incorporation. as amended.
In Witness Whereof, the State Farm General Insurance Company has caused this policy to be signed by its President and
Secretary at Bloo„miin,�gton, Illinois.
1�is.
Se eta7y President
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: California Department of Insurance
Consumer Services Division
300 South Spring Street
Los Angeles, CA 90013
Or call toll free: 1 -800.927 -HELP
Prepared
MAY 10 2016 Copyright State Farm Mutual Automobile Inswance Company. 2000
CMP -4000 Includes copyrighted material oflnsuraace Services Office, Inc, wth is oermissmn
016461 Continued on Next Page Page 6 of 7