COMMON POLICY DECLARATIONS POLICY NUMBER: 2CT864 RENEWAL OF POLICY: Named Insured d Mailing Address (, Street, Town or City, County, State, Zip Code) AUBURN VALLEY SERVICE CORP. & AUBURN VALLEY PROPERTY OWNERS ASSOCIATION & AUBURN VALLEY PUBLIC FINANCING 885 AUBURN VALLEY ROAD 2CR567 AUBURN CA 95602 Policy Period: From 0/06/205 to 0/06/206, at 2:0 A.M. Stdard Time at your mailing address shown above. BUSINESS DESCRIPTION: HOMEOWNERS ASSOCIATION/COMMUNITY SERVICES FORM OF BUSINESS Individual Joint Venture Partnership Orgization (other th Partnership or Joint Venture) Limited Liability Compy X Corporation Other Audit Period: Annual unless otherwise stated: ANNUAL FTZ Code: IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PART(S), BUT ONLY FOR WHICH A PREMIUM IS INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. Commercial Property Part 886.00 Commercial General Liability Part 3,356.00 Commercial Inld Marine Part NOT COVERED Commercial Oce Marine Part NOT COVERED Commercial Professional Liability Part NOT COVERED Commercial Automobile Liability Part NOT COVERED Liquor Liability Part Crime Part: NOT COVERED NOT COVERED Other s: Terrorism NOT COVERED Premium Total 4,242.00 Other Charges: STATE TAX (3.0%) STAMP FEE (.200%) 27.26 8.48 State Surplus Lines License # 048990 GRAND TOTAL 4,377.74 MDIL 000 08 Page of 2
Producer Number, Name d Mailing Address 05690 M.J. HALL & COMPANY, INC. 709 N. CENTER STREET STOCKTON CA 95202 Inspection Ordered: Yes Program Code: No X Endorsements Forms d Endorsements applying to this Part d made part of this policy at time of issue: SEE SCHEDULE OF FORMS ATTACHED. These declarations, together with the Policy Conditions d Form(s) d y Endorsement(s), complete the above numbered policy. Countersigned: Date 0/2/205 SB By: AUTHORIZED REPRESENTATIVE MDIL 000 08 Page 2 of 2
COMMEIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS POLICY NUMBER: 2CT864 X X If Supplemental Declarations Is Attached RETROACTIVE DATE THIS INSURANCE DOES NOT APPLY TO "BODILY INJURY", "PROPERTY DAMAGE" OR "PERSONAL AND ADVERTISING INJURY" WHICH OCCURS BEFORE THE RETROACTIVE DATE, IF ANY, SHOWN BELOW. RETROACTIVE DATE: NONE (ENTER DATE OR "NONE" IF NO RETROACTIVE DATE APPLIES) LIMITS OF INSURANCE General Aggregate Limit (other th Products/Completed Operations) 2,000,000 Products/Completed Operations Aggregate Limit 2,000,000 Personal d Advertising Injury Limit,000,000 Any One Person or Orgization Each Occurrence Limit,000,000 Damage to Premises Rented to You Limit 00,000 Any One Premises Medical Expense Limit 5,000 Any One Person ALL PREMISES YOU OWN, RENT OR OCCUPY Loc ADDRESS OF ALL PREMISES YOU OWN, RENT OR OCCUPY 0 CORNER OF BELL ROAD AND LONE STAR AUBURN CA 95604 CLASSIFICATION AND PREMIUM Loc Code Rating *Premium Other Advce Premium Classification Basis Basis Basis Pr/Co All Other Pr/Co All Other 0 4670 Each 38 PER EACH INCLUDED 0.00 INCLUDED,380.00 HOMES R/A CLUBS - CIVIC, SERVICE OR SOCIAL - NO BUILDINGS OR PREMISES OWNED OR LEASED EXCEPT FOR OFFICE PURPOSES (NOT-FOR-PROFIT) 0 4945 Each 7 PER EACH INCLUDED 25.00 INCLUDED LOTS R/A VACANT LAND (FOR-PROFIT) 75.00 0 48727 Each 3 PER EACH INCLUDED 55.00 INCLUDED 465.00 STREETS, ROADS, HIGHWAYS OR BRIDGES - EXISTENCE AND MAINTENANCE HAZARD ONLY *(a) Area *(c) Total Cost *(m) Admissions *(p) Payroll *(s) Gross Sales (u) Units *(r) Gross Receipts (e) Each (o) Other Premium Basis identified with a * is per 000 of selected basis. Total Advce Premium These declarations, together with the Common Policy Conditions d Form(s) d y Endorsement(s), complete the above numbered policy. FORMS AND ENDORSEMENTS SEE FORMS SCHEDULE MDIL 00 2,020.00 MDGL008 08 Page of
POLICY NUMBER: 2CT864 Loc. COMMEIAL GENERAL LIABILITY COVERAGE PART SUPPLEMENTAL DECLARATIONS ALL PREMISES YOU OWN, RENT OR OCCUPY ADDRESS OF ALL PREMISES YOU OWN, RENT OR OCCUPY CLASSIFICATION AND PREMIUM Advce Premium *Premium Other All Basis Basis Pr/Co Other Pr/Co All Other Loc Code Rating No. Classification Basis 0 9585 Cost of Work* 56,000 PER,000 INCLUDED 6.00 INCLUDED 936.00 CONTRACTORS - SUBCONTRACTED WORK - IN CONNECTION WITH CONSTRUCTION, RECONSTRUCTION, REPAIR OR ERECTION OF BUILDINGS- NOT OTHERWISE CLASSIFIED 0 49950 Flat Charge OTHER OTHER INCLUDED FLAT INCLUDED HIRED AND NON-OWNED AUTO 400.00 *(a) Area *(c) Total Cost *(m) Admissions *(p) Payroll *(s) Gross Sales (u) Units *(r) Gross Receipts (e) Each (o) Other: Premium Basis identified with a * is per 000 of selected basis. Premium for this Supplemental Declarations,336.00 MDGL 009 08 Page of
COMMEIAL GENERAL LIABILITY POLICY NUMBER: 2CT864 ESSEX INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DEDUCTIBLE ENDORSEMENT This endorsement modifies insurce provided under the following: COMMEIAL GENERAL LIABILITY COVERAGE FORM LIQUOR LIABILITY COVERAGE FORM OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE FORM PRODUCTS/COMPLETED OPERATIONS COVERAGE FORM PROFESSIONAL LIABILITY COVERAGE FORM RAILROAD PROTECTIVE LIABILITY COVERAGE FORM OTHER COVERAGE FORM (SPECIFY): Please refer to each coverage form to determine which terms are defined. Words shown in quotations on this endorsement may or may not be defined in all coverage forms. SCHEDULE. Bodily Injury Liability Amount d Basis of Deductible PER CLAIM or PER OCCURRENCE 2. Property Damage Liability 3. Bodily Injury Liability d/or Property Damage Liability Combined 500 4. Personal d Advertising Injury Liability 500 5. Professional Liability 6. Other (describe): 7. Liquor Liability EACH COMMON CAUSE N/A If this box is marked, the deductible for "property damage" is amended to apply on a Per item, Per Claim basis. A. Our obligation to pay damages on your behalf under Bodily Injury Liability, Property Damage Liability, Personal d Advertising Injury Liability, Professional Liability, or Liquor Liability, or y other coverage under this policy referenced above, applies only to the amount of damages in excess of y deductible amounts stated in the Schedule above. B. For coverages other th Liquor Liability, the deductible amount will be on either a per claim or a per "occurrence" basis. For Liquor Liability, the deductible applies on Each Common Cause basis. Your deductible applies to the coverage option d to the basis of the deductible indicated by the placement of the deductible amount in the Schedule above d will include loss payments, adjustment, investigative d legal fees d costs, whether or not loss payment is involved. The deductible amount stated in the Schedule above applies as follows: MEGL 0048 03 3 Includes copyrighted material of Insurce Services Office, Inc. with its permission. Page of 3
POLICY NUMBER: COMMEIAL PROPERTY COVERAGE PART DECLARATIONS DESCRIPTION OF PREMISES Bldg Class Code 2CT864 Location Address CORNER OF BELL ROAD & LONE STAR AUBURN CA 95604 Class Description: of Stories Year Built X X If Supplemental Declarations Is Attached Occupcy Construction Location Address of Stories Year Built Occupcy Construction Class Code Class Description: COVERAGES PROVIDED Insurce at the described premises applies only for coverages for which a limit of insurce is shown. Limit Of Insurce Covered Causes Of Loss Valuation* Coinsurce** s BUILDING-PUMP HOUSE EQUIPMENT IN PUMP HOUSE GENERATOR WELL PUMP ELECTRICAL PANEL WELL PUMP 4,000 Special x-theft 30,000 Special x-theft 2,000 Special x-theft 5,600 Special x-theft 8,000 Special x-theft 7,000 Special x-theft ELECTRICAL PANEL 0,000 Special x-theft WELL PUMP 0,000 Special x-theft *AA-Agreed Amount *ACV-Actual Cash Value **If Extra Expense, Limits On Loss Payment *-Replacement Cost Term OPTIONAL COVERAGES Applicable only when entries are made in the schedule below. Limit Of Insurce Covered Causes Of Loss Valuation* Coinsurce** s Equipment Breakdown 24.000 *AA-Agreed Amount *ACV-Actual Cash Value **If Extra Expense, Limits On Loss Payment *-Replacement Cost Term MDCP 000 02 3 Page of 2
MORTGAGEHOLDERS Mortgageholder Name And Mailing Address DEDUCTIBLE,000 X Per occurrence Per Location Per Building Exceptions: These declarations, together with the Common Policy Conditions d Form(s) d y Endorsement(s), complete the above numbered policy. FORMS AND ENDORSEMENTS: SEE FORMS SCHEDULE MDIL 00 TOTAL PREMIUM FOR THIS COVERAGE PART: 440.00 MDCP 000 02 3 Page 2 of 2
COMMEIAL PROPERTY COVERAGE PART SUPPLEMENTAL DECLARATIONS POLICY NUMBER: DESCRIPTION OF PREMISES Bldg Class Code 2CT864 Location Address CORNER OF BELL RD. & LONE STAR AUBURN CA 95604 Class Description: of Stories Year Built Occupcy Construction Location Address of Stories Year Built Occupcy Construction Class Code Class Description: COVERAGES PROVIDED Insurce at the described premises applies only for coverages for which a limit of insurce is shown. Limit Of Insurce Covered Causes Of Loss Valuation Coinsurce** s ELECTRICAL PANEL 9,000 Special x-theft WATER STORAGE 60,000 Special x-theft ELECTRICAL PANEL BUILDING-GAZEBO 4,000 Special x-theft 0,000 Special x-theft *AA-Agreed Amount *ACV-Actual Cash Value **If Extra Expense, Limits On Loss Payment *-Replacement Cost Term OPTIONAL COVERAGES Applicable only when entries are made in the schedule below. *AA-Agreed Amount *-Replacement Cost Limit Of Insurce *ACV-Actual Cash Value Covered Causes Of Loss Valuation Coinsurce** s **If Extra Expense, Limits On Loss Payment Term MDCP 00 02 3 Page of 2
MORTGAGEHOLDERS Mortgageholder Name And Mailing Address DEDUCTIBLE,000 X Per occurrence Per Location Per Building Exceptions: PREMIUM FOR THIS SUPPLEMENTAL DECLARATIONS: 446 MDCP 00 02 3 Page 2 of 2