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04-10271_A Y S O REGION 87_InsuranceTo: City of San Juan Capistrano , From: Latoya Cotton 10-21-04 9:32am p. 2 of 1 i, sF _ 1 r'y r Date UMtUturyYI 1 aS�,iN wm ACORa ,ER"TIF1+AE1 10/272004 rm THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Pr LaToya Calton ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE ESIX-Brown & Brown, Inc COVERAGE AFFORDED BY THE POLICIES BELOW. 1117 Perimeter Center West, #N-400 Atlanta A 30338 1-800-342-4371 INSURER Clarendon National Insurance Co. www.soccer.org A INSURER B Insured American Youth Soccer Organization INSURER C INSURER 12501 S. Isis Avenue Hawthorne CA 90250 D OVE OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICYPERIOD INDICATED. THE POLICIES 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. POLICY POLICY EFFECTIVE EXPIRATION INSR TYPE OF INSURANCE POLICY NUMBER DATE DATE LIMITS LTR GENERAL LIABILITY COMMERCIAL GENERAL LIAR ECP 000806-01 7/1/2004 7/1/2005 EACH OCCURRENCE $ FIRE DAMAGE (Any lnre)S MED EXP one son) s CLAIMS MADE OCCUR Sexual Abuse ECP 000806-01 7/1/2004 7/1/200$ PERSONAL & ADV INJURY S I-arTIG. L.Val GENERAL AGGREGATE $ None ECP 000806-01 7/1/2004 7/1/200$ GIEN AGG UMI I A LI P R PRODUCTS-COMP/OP AGG f -AbUse O es f POLICY PROJECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANV AUTO B ODILY INJURY ALL OWNED AUTOS W) $ SCHEDULED AUTOS BODILY INJURY HIRED AUTOS (PW mcideno $ NON -OWNED AUTOS PROPERTY DAMAGE (Per a keen) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT f OTHER THAN FAA f AUTO ONLY: AGO$ ANY AUTO EXCESS UABILITY EACH OCCURRENCE S AGGREGATE s OCCUR r7 CLAIMS MADE S $ DEDUCTIBLE $ RETENTIONS WORKERS' COMPENSATION & STATUTORY LIMIT THE - - EL EACH ACCIDENT f EMPLOYERS' LIABILITY EL DISEASE - EA EMPLOYEE f EL DISEASE -POLICY LIMIT f DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS The Certificate Holder is an Additional Insured with respects to their involvement in AYSO sanctioned activities only. t:E ZW!,CATE HOLDER f tATlt l ¢ r y AYSO Certificate for 2004-2005 season SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL City of San Juan Capistrano DAYS WRITTEN Parks and Recreation Department LEFT, FAILURE MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRE. SENTATIVES. ' 10 Da for Non Pa M of Premiurn AUTHORIZED REPRESENTATIVE San Juan Capistrano CA 9267$ P Mike A Price }„y-,ryyi-- 4,.:fS" A(`JICh 7R:C.J7Mi1 �,i ., ��n �'.i.�-.fTA'E✓LLC�;�'.��t�tit�',.,� � +Ciz•:- POtRA1'�At,;08sE �-�a: .. To: C;ty of San Juan Capistrano From: LaToya Cotton • 16-. IMPORTANT 10-21-04 9:32am p. 3 of ! If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. A statement on this certificate does net confer rights to the certificate holder in Ileu of such endorsoment(s). If SUBROGATION IS WAIVED, subject to the tams 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 aeu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does net constitute a contract between the Issuing insurer(s), authorized representative or producer, and the certificate holder, nor does It aff nnallvely or negatively amend. extend or alter the coverage afforded by the policies listed thereon. ACORD 25-S (7/97) created at www.e CertsONLiNE.corn To: City of San Juan Capistrano 0 POLICY NUMBER ECP 000806-01 American Youth Soccer Organization From: Latoya Cotton 10-21-04 9:32am p. 1 of A COMMERCIAL GENERAL LIABILITY CG 20 11 11 85 10/27/2004 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE 1. Name of Person or Organization (Additional Insured): City of San Juan Capistrano Parks and Recreation Department San Juan Capistrano CA 92675 2. Designation of Premises (Part Leased to You): 3. Additional Premium: (if no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person(s) or orgam- zation(s) shown in the Schedule, but only with respect to their liability arising out of the ownership, maintenance or use of that part of the premises leased to you and shown in the Schedule and subject to the following additional exclusions: City. of San Juan Capistrano Parks & Recreation Dept. San Juan Capistrano, CA 92675 This insurance does not apply to: 1. Any 'occurrence' which takes place after you cease to be a tenant in that premises. 2. Structural alterations, new construction or demolition operations performed by or on behalf of the person or organization shown in the Schedule. 32400 PASEO ADEAANTO SAN JUAN CAPISTRANO, CA 92675 (949) 493-1171 (949) 493-1053 FAX www.sanjuancapistran0.org November 8, 2004 Mike Schmidt, Commissioner AYSO Region 87 3833 Vista Blanca San Clemente, CA 92672 Dear Mr. Schmidt: Jwaa IAGAPIAARI Asuausxca ` (461 1776 MEMBERS OF THE CITY COUNCIL SAM ALLEVATO DIANE L. BATHGATE WYATT HART JOE SOTO DAVID M. SWERDLIN An original, executed License Agreement related to use of the concession stand at San Juan Capistrano Sports Park and Cook Park/Cordova is enclosed for your records. Thank you for forwarding evidence of insurance coverage. Please keep in mind these documents must remain current or use of the concession stand must stop until our office receives current documents. If you have questions specific to the contract, please contact the project manager, Karen Crocker, Community Services Manager (949) 443-6389. City glerk cc: ` afen Crocker, Community Services Manager Al King, Jr., Community Services Director San Juan Capistrano: Preserving the Past to Enhance the Future