96-116
The Applicant/Permittee heraby al)1"". by affidnq their .iqnatura to tbia penit to bold the City ot
campbell, it. otfieera, aCJenta and aaploy", tree, ..te and bazal... froa any ~ia or ~ for
clamaCJe. re.ul tinCJ froa the work covered by tbi. puait.
The Applicant/Permittee hereby acknowladCJ.. that they bave read and undaratand both the fZ'Oftt and !
back of this permit, ~d th.at they will infOD th~,1r oontractor(.) of the 1Iltorution. .. .
ACCEPTED ~ /' r' / ? . '. //7\.. ~ -C' -c ~. " ~ i / ..s I <;. .)-
ApPl~t (PermittH~ print~.iCJD" '. ~._ P'/ . . ~ .../J ,-7 .9-tf ( ~./ / I I
t::..11-e~,'~ 1'-'" HcC'.ft'~/i~ ~~ ~~ .~~ I
~U Z:;" I,
ROTES: ALL WORK SHALL CONFORM WITH THE A'1"1'ACBED, APPIUVBD PI.AIfS AlII) ALL APPLICULE CAIIPDLL '-C//~;;~
STANDARD DETAIlS AND CONDITIONS. t/'"
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ern or c:AIIPBELL
DBP'1'. or PUBLIC WOlUtS
70 North Firat St.
C&apbell, CA 15008
(408) 866-2150
0IIIIBIl U\iYlr.uw ..1
.JO PEE mI(!ROAC5DmIftI ftIIIIrl'
(for workin9 within tile
public r19bt-ot-vay)
($3.5" ~ _.1Ie.... of. ..1IOrk)
I.sued :3 L:z.r
'1b--//IP
.... ~ 110.
Z-"f. tU.
Application Date /,; ') ,; 91 f)
Application apiru 111 J _.
APPLICATION - Application 18 bereby ..de for a Public WOrka ~t 111 acc:ordance vitll CUipba11
lIunicipal COde, Section 11.04. (Application expiru 111 6 mntha if the pen1t 18 not l8aued)
A. Work aclc1ra.. I I 3 "'1 0'r~' -y VL e.' (; D,~ I U-C.
a. .ature of work: (-7 V L-( in I Vl or, C? .{" 2 c< :5' h -14-' -< (" >
,/
L ,.., ~ L'r_ v'/
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'~/"'''''''''c'
C. Attach three (3) copie. of a cSnwinCJ abowinCJ the location, extent and diaenaions of the work.
The drawing aball abow tile relation of tile prapo8ad work to axiatiDg t.p~. When
approved by the City Enqinaar, Aid cSnw1n; becaMa . paR of W. pen1t.
D. All work aball confora to tile City'. General CDDditions, standard COIuItnction I'rcwi.ions and
standard COnstruction Detail. for Public Works COnstruction, ft. GeDenl Pera1t Conditions
li.tad. on tile rever.. .ide, and Special Proviaiona for tbia puait, litRed below. FaUure to
abide by the.e condition. and provl8iona ~ l'9ult in job abut-cloWll and/or forf.it:un of
Faithful Pertorunca Surety. ALy't 1'M-e '"11}lJ.1""J~t;; 2~O-(P'S'LI-'>
.... ot Appllc::;\,f"'!;:,IL~ E:..- I lc',e' V \ rvt I-i 0<."'..( (.<-.-- ftlepbonea .;3'/ ( -.;:L 3,..2 "/
Addres. ! l :3 c;, c:/-\....../le .;, (") r I U--<:::' '--t ~(,;l - C 12 c'(
COJIIplate and attach Workara' COIIpanaation and contractor IDroraation foraa. fQ)( 1-91.... '1-fOf.
THE CON'l'RAC'l'OR HOST HAVE 'l'HIS PERMIT AND APPROVED PUNS AND lIDS'!' UlWfGB '1'0 IID'l' WI'1'II '1'BE P.W.
INSPEC'l'OR AT '!'HE SITE AT LEAST TWO DAYS IIEPORE S'!'AR'l'ING WORlC.
NO'l'ICE HOST BE GIVEN '1'0 PUBLIC WORKS AT LEAST 24 IIOCItS DPORE ItI!:S'l'ARl'DI AllY ~.
SPECIAL PROVISIONS
ti1;'::i~?:;'~ ~k ~(-t.7 0~!~jdJ A(,~
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En9inMr ' Date tI:I
iru , .mtba after t:ba date of t.---. t:l
=
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(100' OF DG. JIII'1'.)
t: R1 PERMI'1'
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(SD CJ'1'DR DDB)
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FRCM BOZZUTO INS
MAR. 5.1996 4:03PM P 1
Ph NO.: 4083775741
_A ~_UI1U... ~c:n"t'lrl~,"'I, U""iI..IMa'LI['I"""I..~""n " " 0 2 - 2 0 - 9 6
PAOOUCEA THIS CERnFICATE IS ISSUED AS A MATTEA OF INFORMA nON
BOZZUTO IN,SURANCe: ONLY AND CONFERS NO RIGHTS UPON THE CERnFIC"~
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
34 2 5 S BASCOM AVE ~ 1 0 0 ALTER THE COVERAGE AffOROI!D BY THI! POUCIES BI!LOW_
CAMPBELL CA 95 008 COMPANIES AFFORDIN!_~.OVE"AaE!
COMPANY
A AMER INT I L S PEC LINES INS CO
WSuN!D '-
COMPANY
ALYS TREE TRIMMING B
455 WEST V IRGINIA ST:~EET COMPANY
SAN JOSE CA 95 725 C
,
COMPANY
I D
,
THIS IS TO CERTIF( THAT 1'}!E POllCIE!' OF INSURAN<:E USTI:D BElOW HAVE BEEN IssueD TO THE INSUIlfD NAMED ABOVE FOR n-lE POlICY PERIOD
INDICATED. NOTWr'HSTANOING ANY RElllllREMENT. TERM OR CONomON OF ANY CONTRACT OR OTHER OOCUME,NT WITH RESPE(~T TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY .1>!A'r AlN, ~E INSURANCE AFFORDED BY THe POUCIES OESCR.eco HEReiN IS SUBJECT TO AU. THE TERMS.
fXCLUSIONS AND I,ONomONS OF suef: POLICIES. LIMITS SHOWN MAY HAVE IJI;EN REDUCED BY PAID ClAIMS,
eo 'M'! 01' IlI,'SURANCE I'OUC f I'IlJMEA POUCy B'FE<:TNE IlOLlCY EXPIIVoTlON UtlIl'S
LTIl DAlE {MtMlOIYVl DATE (ftlMOOi'Nl
GiNiRAL UNIIJTY GeNEAAl AOOREG/lTE a1 0 0 O. 0 00
A "7 COMMERCIAl. Ql:\'EFW, LIAIll.ITf 9 'l644 - CA950422 6 04 - 12 - 95 04 - 12 - 9 6 I'l'IOC\JCTS CCMP/OI' AQQ ,l. 0 0 o. 00 0
=:J ~ MADE [l] OCCUR PEIlSQNAl & AOV INJURY 150,0 0 0
- 0WNEIl'S & CONTRACTOI'I'S PRl;.T !ACH OCC\JlftlllCl ,5 0 O. 0 0 0
I'Il\i DAMAgE (Any - lItw) a50 000
MiD EXP{AIlV ..... 1*-1 a1.0 0 0
~ LWIlUTf
COMIlINED SINGLE LIMIT a
- .....y AUTO
.-- AU. OWNED AUlas llOOll. v INJUAV
,
SCliEOULED AUlOS (Per -I
f---
f-- HIREO AUTOS BOOILV IN,AjRY
NON-OWNED AUTOS ,Per accIcJen1l ,
f--
f-- I'flOl'emY OAMAIIE a
~ l.IMlJTY AUTO QN.V E.A 4CCIDENT ,
f-- "'" MO ontE!I 1HAN AUlO OM,y,
f-- EA~ ,o,CCIDEHT a
N3GIliBATi s
=r=nY~ E,t.CH OCCURRENCC S
AGGREGATE ,
ODl&l nwt ~ I'OIlM $
WORKERS COfoI'ENSI.'l1ON AND I :;;"$T~1Jf.. I IO~
8IPl.OYal6' LNIlJl'\' ACClDetT
B.. EACH a
l)4E ~ORI -.R: EL oW!( - POL iCY LIMIT a
PIlmlERSaECUTNE
0I'I'IC9lS ARE; EL OISEASl; - EA I""PLOva; S
01tlER
OESCAPTIOII 01' O~~lPIew. Il&II
SEE ADDITIONAL INSURJ:D ENDORSEMENT FOR PRIMARY WORDING .
PERMIT # 96 - 1 16
"
!HOU\D NfY OF 1l1li: MOve 0EllCl'1IIEO I'OUCIEI IE CMeEUJ!O III'ON TME
ADDITIONAL I NSURE:D DllRATIOH OAlE 1HfIIIEOF. THE I9llUING COMIINlY W\I,~ ~
CITY OF CAMPBELL ~!",Y8 ~ NOTICE TO n4E CfRl1'lCATi MOllll!'R NAMED TO 1)lE lUT.
70 N . FIRST STREET
CAMPBELL, CA 95008 2SZ
' ~
'A~).;:wm~,~t~:~N:Il'i,~:H:i:@:~,;.~,,~,',.~@:gI'~'H'ti.I,\@{,~,:~:~M:~'\~~"~-N':::~'N:'!,:i"i::::i~'~%'ffi:~~<?;1'" ,'" ",:;:;:.8?:'?:~w~'m;:;:'#I~':'~'_:.: "
<r'
FRrM ; BOZZUTO INS
MAR. 5.1996 4:04PM P 2
PI-. NO.: 4083775741
j-mS .:1'<"DORSEl'-LENT CHA.l~GES THE POLICY- Pu:::ASE READ IT CAREFUI.L Y
ADDITIONAL INSURED ENDORSEMENT
I
CITY OF CAMPBf:LL . THIS INSURANCE IS PRIMARY.
n: yot ARE REQUIRED TO ~D k~OTHER PERSON OR ORGANIZATIlJN AS
A~ ADiJITIONAllNSURED ON TEIS POLICY UNDER A WlUTTEN CONlMCT
(IR AG:~\lENT CURRENTLY IN EFFECT OR BECOMfr.rG EFFECTIVE
DURll{}THE TERJ.'v'! OR THE POLICY AND A CERTIFICATE OF INStJRA.NCE
.. . ~
LIS1Dt} THAT PERSON OR ORGN'\j1.U\nON AS A,,~ ADDITIONAL INSURED
HAS BEEN ISSUED, THEN VV'HO IS A2~ rNSURED ( SECTION IT ) IS ,AMENDED
10 INC:.r.JD.E AS AN INSTJRED nIAT PERSON OR.ORGAJ'UZATION (C}J..LED
~'ADDnrON.U INSURED").
THE IN..;URA..'iCE FOR rrl.-\,T ADDITIONAL INSURED IS LIMITED AS
FOLLO'VS:
I. THA1: TH~ PERSON OR ORGA;,'-I1ZATION IS O~"LY A.L~ ADDITIOl'~AL
INSURED FOR ITS LL~lLITY ARiSING OUT OF "Yo-UR v/ORK" FOR OR ON
BE&J.F OF THIS ADDITIONAL IN"SURED; k'\c'I)
: TffC Ul\rrrS OF LIABILITY FOR THE ADDITIONAL lNStTRED ARE niOSE
SPEc:mD IN TEE W"RlTTEN CONTRACT OR .11.GFEElv.rE?-.'T, OR rN THIS
POLICY. \VHICHEVER rs LESS, THESE Ll1vllTS ARE IN"CLUSI\lE OF ,\;,'IT)
ARE UOl IN ADDmON TO THE LilYlITS OF INSUR.A.J.'\iCE SHOvv:--r IN THE
Th':; DECLARATIONS; AND
3 AlL O,fHER POLICY TERi\ifS. CONDITIONS A.J.',rD RESTRICTIONS ALSO
APPix, INCLUDING. BUT NOT LJ1vGTED TO THE '"OTHER INSURANCE"
PROVISIC'NS,
THIS E1'l1)03.SEivIENT A.ND ~'lY COVERAGE'S PROVIDED HERETI'j APPLY
eN!. Y IC T;{E POLICY TO W"HICH IN rs ATTACHED A~'\lD IS. NOT EXTENDED
TO l~'\fY ,)T:rER P'JLICY ISSUED TO THE lNStJRED.
PREynm:r: INCLUDED,
LA C-AD I 992
FEB-20-96 TUE 15:48
MORGAN INSURANCE
FAX NO. 4084350418
P. 02
l~!!~~I~~,~lillt..I.l.]I_pJ~it~~l~~~~~~{~~~l~?l~~~~~!0I~I~~;~~~~J.wv~~~~~;,;;; ~
'ROO\IC~" Mo'rga'~"" I~~sti~~~;~~ 'Agency .. . v v_v_yAv V_" THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
, ONLY AND CONFERS NO RICHTS UPON THE CERTIFICATE
1977 0 Toole Avenue, Ste. B102 HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
San Jose CA 9513 1 COMPANIES AFFORDIN.G. COVERAG,.E
(4 Q 8 ) 4 3 5 - 542 2 COMPANY
A FARMERS INSURANCE EXCHANGE
'" ..-... .-..-- - c...._
1N$V1IfD COMPANY
Apol inar Eliseo B - - .- . . ,. I!!! n
,
4 55 w Virginia Street COMPANV K. 1:,"", p;;; I ".. r..
.
C
San Jose CA 9512 5 COMPANY FEB 2U 1996
(r4 0 8 ) 2 80 -6 545 0
THIS IS TO CERTIFY THAT THE POUCIES OF INSURANce LISTED BELOW HAve BEEN IssueD TO THE INSURED NAMED ABOy!:!'"OR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH 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 CONOmONS o~ SUCH POUetES, I.IMITS SHOWN MAY HAVE BEEN REOU~~D _~~AlD CLAIMS.
-- _....._._...~...__.
co TlPE OF IN5URMCE POlley NUM.~" I'QUCY EffECTIVIl I'QLICY EXI'IMTIQtl LIMITS
LTft DATE (IIIM/DOIVY) DATI: (MMlDDIVY)
GENElW.lIA8lUTY GE/llEAALAGGREGATE $
- / / / / PROCUC'TS. CONll1!OI' "'GG : S
CQt.'l\IIiJ'lC1.IoL GeNERAL UA!IIUTY I
- =:J ClAIMS MADE D OCCUR I
PERSONAl & AOV INJURY S
-'--'
- OWNER'S" CONTRACTOR'S PROT EACH OCCURReNCE $
F1RE~ (Arlyg,,,.f>,,,) &
-- _._- ..'n
MEO EXP (Anyone person) $
A ~TOM08ILf LIABIUTY
124 6 9 -3 0 18 06 /1 9/92 06/19/96 COMBINED SINGLE LIMIT $
ANY AUID -
- ~ .ft_-,., .......w..,-, .--..... -..
X ALl OWNED AUTOS SODIL Y IIllJl,JRY
SCHEDULED AUlOS 111~Ile""..ctIl $25 0000
- "--..._----_.-.._~_...._. ....-..-..-
-.~ HIREO AUTOS BODILY INJUm-
IIlON-OWNED AUTOS (Per SCCidl!nt) $500 000
r--
f---- - PROPERTY DAMAGE $100
0 00
GARAGi lIA8ll1TY I AUTO ONLY. EA ACCIDENT $
t~l ANY AUTO / / / / _.,._.._.--~--...._---.....-
OTHER THAN /WID ONLY . .'. .
I F.A01 M'..ClOCNT <;
i AGGREGATE $
A EXCESS LIABILITY EACH OCCURRENCE 51 0 00 000
/13 /95 /13 /96 y..--...-.....-,.-......-...,....-..
M UMBRELLA FORM 6 008 0 - 0 7 - 51 06 06 AGQREGATE sl f 0 00 , 00 0
OTHER THAN UMBRElLA FORM S
_L$TAI~TO~ UMIIS .......... '.
WOflI(EAS COMPEHSAnON AND
D1PlOYI!RS' LIABILITY / / / / EACH ACCIDENT $
H INCL u__ "c.--
THE PROPI'lIETORf DISEASE. POLICY LIMIT $
PARTNEAS/EXECUTIVE
OFFIcats AAE' EXCL DISl:Me - EACH EMPLOYEE S
OTHEII
/ I / /
PIlliC"'PTI011 OF OPERATlONI;/l.OCATlOICS/'nNICLCSISP[CIAlITEMS
ADDITIONAL INSURED TO READ : II City of Campbel 1 Its Officers Employees
, ,
and Volunteers II
pS(',.,.,;-i-- SHOUUJ MY OF THE jl~E OBell/am POLICIES II[ CANCEllED BEFORE THE
City Of Campbell CJl -//~ EXPlMl1Qfl DATE TMiEAEOF, THiE 1c.&uING' eoM_ WILL IIllS. an u MAIL
Additional Insured -3..0 DA't'S WltfTTEN NOTlCr TO THE CEllTlFlCATE H(){J)ER NAMED TO THE LEl'T,
70 N . First Street .Kr:.....-i lIB Mnll 1'1011 1I11-n am, U Imrrili Nt ..WMf4811 tA WiWILlllf
Campbell CA 95008 er Atrr fUrr. urerr 1..5 "l'nr~Aflr. . JM -_1lI IR IliI'REllllrMfla
AUTMORIZED
~-~,~#;@:~jW.f!gj:;Wg}~g:.':;~@~~~;~#f#r;~H;'t.'~I#~i~;t:1@",~;;tt{N:t..~.~i~;~~tttr~f:.~~~_'
'4
-----14:29-01;12;'96
PAGE 01
J~H 111) '96 14:47
FROM SIEIIEr"; POL~' BID'::, F':P
F'HGE , (102
j (ft-tf- '
To Aly"TreeTrimmi ~Ji ~~.Jt1~~}l(
Attention: Ed: p u Dr.. r c~ t--lJrk) I fl.:l;.{je elf) r
I would like to havo y<lU the wQt1( we discussed yesterdiiY..but I feel that wen 8trwtCT,fng-my
budget will only lei me to $1500. Would you be willing to \.kJ the wo~ for that amounl1
Perhaps WQ could tal< ut backing out a IN" Items..like topping the '1ln. bush (lantana?) by
the pine tree-~r maybe oould cut down the deadlhalf dead bushes and have you do only the
,tump cleanup. I cons' r everything else very eritiCt\1 and outSide of my ability to handle.
I was very impressed wi the caliber of your knowledge. Certainly, Jane Miller was extremely
complementary regard' the quality of tho work !.M has had done by AIy's. I know that you will
be able to dO a great' fOr me.
It W8 can get the price t $1500, I am ready to autholU. the work (as soon as the ~ork on
insurance and the signing is complete for the city gf Campbell). I have attached 4 page8
of iru,fNdions on insura ce requirement8lpaperworl<. ""ro" no issue with your inaurance
levels, only a require to complete the insurance certificate and ~ign the penl1it requeet. In.
fax number to sood lhe flsurance certificate is Jl6 O'1SJ (attentr,n: ;c"11dy W.-rtlll, Public
'N\J,i\& lraGr.cctor). He s the permit fonn that I fillfld out laA' week which would require yo..r
signature.
me 10 two friends whO are interested In hillYinu oome tree
done and told them I would follow UP with the results of your wort<.
Please call to !tit me 'II how you would like to pr~. J'II be ready to sign your wori<
estimate and start mo~i '7',., f~",>
Sincertlly,
~~
Eileen Hoefler
371.2324 (home)
. 492-6129 (office)
11.t,jt" l' ,)
\.JH,' ~.' Nop
." '......1
IJ< A. i ,'{.;!\
~ C2Ly
On. ~ ~~-"'A.~7 .
IA/~c!
STATE
COMPeNSATION
INSURANCe
F=UND
P.o. BOX 420807. SAN FRANCISCO, CA 94142-0801
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
FEBRUARY 3, 1995 POLICY NUMBER; 0133226 - 95
CER11F1CATE EXPIRES: 2 - 26 - 96
I-
APOLINAR, ELISEO P
ALY'S TREE TRIMMING AND YARD CLEAN UP
455 W VIRGINIA ST
SAN JOSE CA 95125
JOB: PROOF OF INSURANCE
CERTIFICATE
L
This IS to certify that we have Issued a valid Workers' Cornponsatlon inSUr3rlCe policy in a form approved by the California
Insurance GOrrHlllSSl0ner to the employer namQd below for the policy period indicated.
This policy is not subject to cancellation by the Fund exc(lpt upon ten days' I1dvance wntten notice to the employer.
We will also gIVe you TEN days' advance notice should this polley be cancelled prior to Its normal expiration.
This certificate of insuranco is not an Insuranco policy and does not amend. extend or ~lter the coverage afforded lJy the
policies listed herein. Notwithstanding any requirement, terlO, or condition of any contract or other document with
rqspect to which tl1is certificate of insurance may be issued or may pertain, the Insuranco "fforded by the policli~!';
described herein is subject to all the terms. exclusions and conditIons of 5uch poHcios,
~~
PRESIOENT
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURKENCE
EMPLOYER
r-
APOLINAR, ELISEO P
ALY'S TREE TRIMMING AND YARD CLE~N UP
455 W VIRGINIA 5T
SAN JOSB CA 95125
. .
....-. __ a A_All"'!' ftlUfteft
lSIIJl: DATE ;,...t1J!jrt r J
A..,g.,.
'~U""m..,1: alnu..n
THIS BINCJ:R IS A TfMPOAAR'
SIDE OF THIS FORM
0lIl00\ICfJII
~URANCE CONTRACT, SUBJECT TO THE C
04-06-95
"1T10NS SHOWN ON THE REVERSE
C~ANY
MtOB'I NO
AISLIC
BOZZUTO INSURANCE
2542 S. BASCOM AVE.
CAMPBELL,
OM!
fll'ICTM
TIll!
t1ATli ElIPIf\ltoTION
'-
ST. 110
CA 95008
04-l2-95
..,.
PM
1 t Ql AN
04.12.96
NOON
CODE
SU84;;00E
'!)lIS BIIlOEA is I$U[D TO EJl:1f!.O Covew:lE IN n.e &IllM NAMl'O
(()NPANY 1'[" EllI'IIlING POlICV NO
oUCRPTDN Of O_llON~C\.I~PIJII"" {'n~"g 1 "".,.""
INSUIU:O
ELISEO APOLINAR
ALY'S TREE TRIMMING
455 W. VIRGINIA ST.
SAN JOSE, CA 95125
L.MTS
~ OF"~
~!'EATV CAll'IB OF lO$S
COYElWlE ~()A'"
AIlIOUNT
llfDUCTlllE .,o...1\UtI
>l~'C
ll/IOAO
SPEC
c;eNlllAl. l-.nY
I C~t<CI"" GEI4DW. llAll'l)TY
cv,IIotS .....oE .,C:C\iR
o_ws . CON"IACTOR"S ",",OT
I MODIFIED OCC.
P.D. OED. 2,000
OCNEIW AGGREGATE S 1 1 l) V U , U U
PROD\ICTS COMP/OP AGG I 1, 0 0 0 I 0 0 I
"I:"5~AL I ADY '!'WHV S 5 0 I () U U
u.cH ~C( I 50,000
fIRE O~ (....y """ folel S I) 0 , 000
WED ElII't:N.'iE (My one Ill''''') I 1. 0 0 0
R{TRQ DAre fOR ClAI~ MAl)(
U_ OEOUCTlIll.E
COlLIS'ON
QTHEIl TH~ CO<
EXCESS l....rrv
\iMll'ItlLA ..()f<tI,
Qn1t" TH.,. '.-I,A ~0I1M
ALL '/ENIClES
';CIfEOULEO ~HI<)..$
cOMBINED SINQI,E LIMIT S
iJOOL1 '!UJRY (p.. pelton) S
ROOIL Y INA,lAV (Pel ...~) S
PROf'f"TY O..,.AQi I
MFOICAL PAYMattS I
PtRSOHAL IKAJIIY "'0' S
IININSUIlEO MOtORISt S
S
AC l\llIl CA.'lH V....\If
STA 11'0 '''''OUNT I
OntE"
E~C::H OCCVM9lCE I
^OGfl:Q,t.li I
SfU: INSURED AIo'kNfl')H ,
:;TMVTOR' ~I"".
>"C" ACCIOENT ,
o'Sf.^6E POliCY ~IM' r I
OI~.FACI-I OAPLOV1:~ ,
I\UTOMOflU LWlUTY
I\HY I\UTO
Au. O.....EO .ov I 0$
)CHEOIJlrD AU10$
"'~D AUTOS
~O AUTOS
G~ U....,ty
RfTR() I)ATE FOIl '=LAIM$ ....IJf
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