1999-1124_CULBERTSON, ADAMS, & ASSOCIATES_Insurance CertificateCI9
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HARTFORD EIRE ..TNS CO
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C UL ER`T`SON ADAMS ASS®C JIB( PC)I,DRN EAGLE IN8CORP
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THS IS TO CFRTIFY THAT' THE POLICIES OF I URANM, i�sTEL; BELOW EDAVF REEN I&SULD TO THE INSURED NAMED ABOVE FOR THE „POLICY PFRIOD
INDICATED, NOTWITHSTANDING ANY ifl:Ca13P68E$dEPl7', TERM OR CC' N DMON OF ANY CCBNIRAGT CSFB OTHER DGCEIAAFN] WITH FIFSPEUT TO WRX;H MIS
C ERTII=ICAT -TAI" BE ISSUED on M pL-RLA#N THr luso IY–f-, AFFOROEU- SY :THE PM-JGIr-5 E CoCfl3iiEb FI i IFe 19 SLIEUr C'T TO All THF TLFIMR,
I:XCA.USEi3 S AND N%Ai8 ONE; Or SUCH POLICIES, LIMITS F�ItiOWN MAY HAVE. Iii:- N IiPOUC.ED 9 ®Ain CIAFus
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08/26/98 16:58 FAX 714 5813599 CULBERTSON ,ADAMS IA003/006
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LTAB11LITY ENDORSEl1UNT
CITY OF SAN JUAN CAPISTRANO
CAPI,STRANO VALLEY WATER DISTRICT
32400 Paseo Adelanto
San Juan Capistrano, California 92675
ATTN:
IusuranceCotrtpanyH ado rr
Endarsm=t#
IpolicyNumber 72LTUCZP4035
sementEffectiveDate.A
ssoc, Inc
lvameQ=UXru rgonaut 0, Aliso Vie ' o C
AddressofNamedlnsured 0 0 0, 0 0 0 1 1 0 0
Limit of Liability Any One occurrence/Aggregate S1 ►
General Liability Aggregate (Check one:)
Applies "pest occurrence__;_
Is twice the occurrence limit
Deductible or Self -Insured Retention (Nil unless otherwise specified). Sn i 1
Coverage is equivalent to:
Comprehensive General Liability form GL0002 (Ed 1173)
commercial General Liability "claims -made" farm CGO002
Bodily Injury and Property Damage Coverage is:
"claims -made"
X "occurrence"
If claims -made, the retroactive date is
B. P-0—L-TaAME-NDMEM
This endorsement is issued in consideration of the attached thereto, Notwithstanding
agreed in follows:
inconsistent statement in the policy to which this
endorsement is attached or any other endorsement
1 INSURED. The City and the Water District, its elected or appointed officers, officials, employees and volunteers are
included as insureds with regard to damages and defense of claims arisis:g from; (a) activities performed by or n be
of the Named Insured, (b} projects and completed operations of the Named insured, or (c) premises
used by the Named Insured.
2. CONTRIBUTION NOT REQUIRED. As respects: (a) work performed by the Named Insured for or on behalf of the
Ci or (b) projects sold by the Named Insured to the City; or (c) premises leased by the Named insured from the City,
City -,
the insurance afforded by this policy shall be primary insurance as respects the City, its elected or appointed officers,
f coverage excess
surecs scheduled
officials, employees or volunteers; Or tandunbroken outer insurance® maintained byof the
the City, its elected ed o'r appointed
underlying primary coverage. In e e
officers, officials, employees or volunteers shall be in excess of this insurance and shall not contribute with it_
3. SCOPE OF COVERAGE. This policy, if primary, affords coverage at least as broad as:
(1) Insurance Services Office form number GL0002 (Ed. 1/73), Comprehensive General Liability Insurance and
Insurance Services Office form number GLO404 Broad Form Comprehensive General Liability endorsement;
or,
(2) Insurance Services Office Commercial General Liability Coverage, „occurrence" form CG0001 or "claims -
made" foram CGO002; ar,
08/20/98 16:57 FAX 714 5813599 CULBERTSON ADAMS 4004/006
(3) if excess, affords coverage which is at least as broad as the primary insurance fortes referenced in the preceding
sections (t) and (2).
4. SEVERABILITY OF INTEREST. The insurance afforded by this policy applies separately to each insured who is
seeking coverage or against whore a claim is made or a suit is brought, except with respect to the Company's limit of
liability.
5. PROVISIONS REGARDING THE INSURED'S DUTIES AFTER ACCIDENT OR LOSS. Any failure to comply
with reporting provisions of the policy shall not affect coverage provided to the City and the Water District, its elected
or appointed officers, officials, employees or volunteers.
6. CANCELLATION NOTICE. The insurance afforded by this policy snail not be suspended, voided, cancelled, reduced
in coverage or limits except after thirty (30) days' prior written notice by certified mail return receipt requested bas been
given to the City. Such notice shall be addressed as shown in the heading of this endorsement.
Incidents and claims are to be reported to the insurer at
ATTN:{Title} (Department)
Yeargin Insurance A eco
(Company)
One Technology J729
(Street Address)
Irvine Ca 92618
(Cita) (State) (Zip code)
(949)453 1115
(Telephone)
Helen Lynn (print/type name), warrant that l have authority to bind the below listed
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insurance company and by my signature hereon do so bind this company.
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SIGNAT(3RE O Y A UI k1Vid 71) p9S NiATiVE
(Original signature required on end6rsement furnished to the City)
Yeargin Ins Agency TITLE
CiRG�.NiZATION: 949 453 1115
SS:
One Technology J729 Irvine 9 TELEPHONE:
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