04-1020_ALEXANDER ENGINEERS, INC._Insurance CertificateACORD.a CERTIFICAW OF LIABILITY INSUONCE DATE
w""'
PRODUCER _ - THIS -CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Dealey, Renton &Associates II �i,('I ONLY` AND CONFERS NO RIGHTS UPON THE CERTIFICATE
-1 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
199 S Los Robles Ave Ste 540 a ----- - ---- ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Pasadena, CA 91101
626 844-3070 - r • - ��n n [ -' I ! INSURERS AFFORDING COVERAGE
INSURED INSURER United States_ Fidelity & Guaranty
Alexander Engineers, Inc. - — URER a St. Paul Flre S Marine Ins. Co.
502 W. Route 66, Suite 17P'D - — —
a 3 G l^:;;, S INSURER Great American Assurance Co.
Glendora, CA 91740 _— —
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR 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 CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSRR
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE MIDD/YY
POLICY EXPIRATION
DATE MM/DD/YY
LIMITS
A
GENERALLIABILITY
BKO1226262 10/16/04
10/16/05
EACH OCCURRENCE
S1 000,000
FIRE DAMAGE (My one fire)_
$1,000,000
XCOMMERCIAL GENERAL LIABILITY
CLAIMS MADE LXJ' OCCUR
I
MED EXP (Any One person)
$1 O 000
�
PERSONAL 8 ADV INJURY_
$1. OOO O_OO _
GENERAL AGGREGATE
1$2,000,000
$2,000,000
�GEN'I- AGGREGATE LINT ITAPPLIES PER:I
PRODUCTS -COMP/OP AGG
_
POLICY PROT 'LOC
I—
A AUTOMOBILE
LIABILITY
BKO1226262
10/16/04
10/16/05
COMBINED SINGLE LIMIT
_
yl
ANY AUTO
(Ea accident)
~
ALL OWNED AUTOS
BODILY INJURY $1,000,000
:SCHEDULED AUTOS
�
(Per person)
rX
HIREDAUTOS
X
NON OWNED AUTOS
BODILY INJURY
(Per accident)
$2,000,000
—
PROPERTY DAMAGE I$
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
OTHER THAN EA ACC $
IANY AUTO
AUTO ONLY: AGG $
EXCESS LIABILITY
(EACH OCCURRENCE $
—�' _
1 OCCUR �I CLAIMS MADE
1
AGGREGATE $
$
DEDUCTIBLE
$
_ -
$
RETENTION $
B WORKERS COMPENSATION AND ;WVA7724714
09/01/04
WCSTATU-
109/01/05 LX OFIY IMITS
EMPLOYERS' LIABILITY
B
I E.L. EACH ACCIDENT ' $1,000,000
�E.L.DISEASE - EA EMPLOYEE$1,000,000
IE.L.DISEASE -POLICY LIMIT 11 $1,000,000
C OTHER Professional EDN5850421 1110/16/04 10/16/05 $1,000,000 per claim
Liability $1,000,000 annl aggr.
DESCRIPTION OF OPERATINSILOCATIONS(VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
The City of San Juan Capistrano is named as an additional Insured as
respects general liability for claims arising from the operations of the
named insured.
City of San Juan Capistrano
Public Works Director
32400 Paseo Adelanto
San Juan Capistrano, CA 92675
ACORD 25-S!7/9714 ..F4 WU11441A04
SHOULD ANYOFTHEABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL :6Aa7011XII Q0 MAIL30 DAYSWRITTEN
NOTICETOTHE CERTIFICATE HOLDERNAM ED TOTHE LEFT, BKRWPJIX= jA"AAXiiu=X
MIA0 n ACOnn CDBDrfpwrinM I Ona
Policy Number: BKO1226262
Owners Lessees or Contractors (Form B)
ADDITIbNAL INSURED
Change(s) Effective: 10/20/04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT
CAREFULLY. This endorsement modifies insurance policy under the following:
LIABILITY COVERAGE PART:
Schedule
Name of Person or Organization:
City of San Juan Capistrano
Public Works Director
32400 Paseo Adelanto
San Juan Capistrano, CA 92675
SECTION II - WHO IS AN INSURED is amended to include as an insured the
person or organization shown in the Schedule, but only with respect to liability
arising out of "your work" for that insured by or for you.
The City of San Juan Capistrano is named as an additional insured as
respects general liability for claims arising from the operations of
the named insured.
13:7A40i 1;iii`&9iIRF—W4m
IT IS UNDERSTOOD AND AGREED THAT THIS INSURANCE IS PRIMARY
AND ANY OTHER INSURANCE MAINTAINED BY THE ADDITIONAL INSURED
SHALL BE EXCESS ONLY AND NOT CONTRIBUTING WITH THIS
INSURANCE.
CL/BF 22 40 03 95
11
11
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different
date is indicated below.
(The following "attaching clause" needs to be completed only when this endorsement is issued subsequent to preparat-M. of the policy.)
This endorsement forms a part of Policy No. WVA7724714 ' S
Issuedto: Alexander Engineers, Inc.
By: St. Paul Fire & Marine Ins. Co.
Premium (if any) TBD
We have a right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our
right against the person or organization named in the Schedule. (This agreement applies only to the extent that you
perform work under a written contract that requires you to obtain this agreement from us).
You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work
described in the Schedule.
The additional premium for this endorsement shall be 2-5% of the California workers compensation premium otherwise
due on such remuneration.
Person or Organization
City of San Juan Capistrano
Public Works Director
32400 Paseo Adelanto
San Juan Capistrano, CA 92675
WC 04 03 06
(Ed. 4-84)
Schedule
Countersigned by
Job Description
yywA,, - a, -gam,_
Authorized Representative