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*40, 140 <br /> Certificate of Coverage <br /> for <br /> FIRE DISTRICTS ASSOCIATION OF CALIFORNIA <br /> FIRE ASSOCIATION SELF INSURANCE SYSTEM <br /> P. O. Box 958 <br /> San Leandro, CA 94577 <br /> ...........................•.............................• <br /> Covered Party: Liberty Rural County Fire Protection District <br /> Address of Covered Party: 24124 N. Bruella Road <br /> Acampo, CA 95220 <br /> Coverage Effective: September 1, 1992 <br /> Coverage Terminates: Until Cancelled <br /> Coverage Limits: Part One: Statutory Limit Each Accident <br /> Workers' Compensation <br /> Part Two: $5,000,000 Each Accident <br /> Employers' Liability <br /> Coverage Agreement: Workers' Compensation and Employers' <br /> Liability Funding Agreement <br /> FDAC-FASIS 7/87 & Amendment 11/95 <br /> Coverage Amendments: NONE <br /> Date: October 2g, 2002 <br /> NOT V D WITHOUT A rHORIZED SIGNATURE <br /> FDAC , ASIS <br />