05-0614_BELAIRE - WEST LANDSCAPE INC._Insurance CertificateAC 111!dk iffi:od
............. D ATE isilIk DNY)
FATE19 I I
xo.
T .... ..... .. 05
PRODUCER 909-941-6699
THIS CERTIFICATE IS ISSUED AS A MATTEROF INFORMATION
Driver Alliant Insurance
Jay Freeman
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
3270 Inland Empire Blvd., #100
COMPANIES AFFORDING COVERAGE
COMPANY
A Landmark American Ins Co/STL
Ontario, CA 91764
INSURED
COMPANY
Belaire West Landscape, Inc.
B
P.O. Box 6270
COMPANY
Buena Park CA 90622
C
COMPANY
.. ... .... .. ...
THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY
HAVE BEEN REDUCED BY PAID CLAIMS.
CO
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE (MM/DD/YY)
POLICY EXPIRATION
DATE (MM/DD/YY)
LIMITS
A
GENERAL LIABILITY
LHA127627
2113/05
2/13/06
GENERAL AGGREGATE 9 2,000,000
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE 1XI OCCUR
PRODUCTS - COMP/OP AGG Is 2,000,000
PERSONAL & ADV INJURY $ 1,000,000
EACH OCCURRENCE $ 1,000,000
OWNER'S & CONTRACTOR'S PROT
FIRE DAMAGE (Any one fire) 0 50,000
X BIIPD Ded:
1 1 $5,000
MED EXP (Any one person) $ 5,000
1
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT $
ANY AUTO
BODILY INJURY
(Per person)
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY
lPer accident)
HIRED AUTOS
NON-OWNED AUTOS
PROPERTY DAMAGE a
GARAGE LABILITY
AUTO ONLY - EA ACCIDENT
OTHER THAN AUTO ONLY:
ANY AUTO
EACH ACCIDENT 0
I
AGGREGATE a
EXCESS LIABILITY
EACH OCCURRENCE $
AGGREGATE $
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
WC STATUS
TORY LIMIT OTH-
EIR
EL EACH ACCIDENT $
THE PROPRIETOR/ INCL
PARTNERS/EXECUTIVE
EL DISEASE - POLICY LIMIT
EL DISEASE EA EMPLOYEE T$
OFFICERS ARE: EXCL
OTHER
10 Days Notice for Non -Pay.
DESCRIPTION OF OPEMTIONS/LOCATIONSNEHICMSISPECIAL ITEMS
Re: San Juan Capistrano Public Library Phase 1, Site Work.
City of San Juan Capistrano, its officers, agents and employees are
additional insureds as per form attached.
This cancels and replaces the certificate issued on 6/11/05.
City of San Juan Capistrano
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF. THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
Attn: Brian Perry
.30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
32400 Paseo Adelanto
OUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
San Juan Capistrano, CA 92675
OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
AUT EZED REP ENT VE
_&n
I
4641
• 0
LANDMARK AMERICAN
INSURANCE COMPANY
This Endorsement Changes The Policy. Please Read /t Carefully.
ADDITIONAL INSURED
BLANKET - PRIMARY
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
SCHEDULE
Name of Person or Organization:
City of San Juan Capistrano, its officers, agents and employees.
PER CERTIFICATE ATTACHED
Any person or organization to whom or to whichi you are obligated by
virtue of a written contract or by the issuance or existence of a
permit, to provide insurance such as is afforded by this policy.
(If no entry appears above, information requird to complete this
endorsement will be shown in the Declarations as applicable to this
endorsement.)
SECTION II - WHO IS AN INSURED is amended to incluee 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.
If you are required by a written contract to provide primary
insurance, this policy shall be primary as respects your negligence
and SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other
Insurance does not apply, but only with respect to coverage provided
by this policy.
This endorsement effective: 2/13/2005
forms part of Policy Number: LHA127627
issued to: Belaire West Landscape, Inc.
by: Landmark American Insurance Company
Endorsement No.
RSG 15001 0903
(CG 2010 1185)
Includes copyrighted material of Insurance Services Office, Inc. 1984
with its permission