1999-0803_CULBERTSON, ADAMS, & ASSOCIATES_Insurance Certificate (2)Ar
-CRD,
PRODUCER
INSURED
ALLIED BROKERS/
YEARGIN INSURANCE
15375 BARRANCA PKWY. STE B-201
IRVINE CA 92618
CULBERTSON, ADAMS & ASSOC INC
85 ARGONAUT #220
ALISO VIEJO CA 92656
DAM 08/(03/99
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE, DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR T;H&POLICY PERIOD
INDICATED, NOTWITHSTANDING, ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPE6T"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 ii TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE VOLICY EXPIRATION LIMITS
LTR I DATE (MM1DD/YY) { DATE (MM/DDIYY)
GENERAL LIABILITY ! 7 2 UUCZP4 9 3 5 8/01/99 8/01/00 GENERAL AGGREGATE 1$1 , 0 t) 0, 0 0
--
X. COMMERCIAL GENERAL LIABILITY
PRODUCTS - COMP/OP AGG $1 , 0 0 0, 0 0 0
CLAIMS MADE � OCCUR PERSONAL & ADV INJURY $1, 000,000
f j'OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE ... „$.1..,_,000, 000
II. FIRE DAMAGE (Any one fire} $ 3 Q 0 , (} (} 0
---------- --...............................----
MED EXP (Any one person) $ 10,000
AUTOMOBILE LIABILITY ; 72UUCZP4935 08/01/99 08/01/00 1, 000,000
COMiNNED SINGLE LIMIT $
}_..___I
ANY AUTO
ALL OWNED AUTOS
_ ))SCHEDULED AUTOS
X l HIRED AUTOS
X NON•OWN ED AUTOS
BODILY INJURY $
(Per person)
BODILY INJURY $
(Per accident)
PROPERTY DAMAGE 1$
'I GARAGE LIABILITY AUTO ONLY -- EA ACCIDENT !-
-
ANY AUTO I OTHERTHAN AUTO ONLY:
-EACH ACCIDENT ! $
[ _..._.__ _ ... .._
AGGREGATE!
$
EXCESS LIABILITY 1 72 XHUXM6 4 0 6 8/ 01 / 9 9 8/ 01 / 0 0 EACH OCCURRENCE $1, O O O, 0 0 0
ry_._- -- - - - ---- - ---- - ....._..---............
X UMBRELLA FORM $ AGGREGATE
� ...............................
OTHER THAN UMBRELLA FORM $
WORKERS COMPENSATION AND WC STATU- TH-f
i TORY LIMITS ER
EMPLOYERS' LIABILITY i --
EL EACH ACCIDENT; $
THE PROPRIETOR/
PARTNERSIEXEGLITIVE INCL EL DISEASE -POLICY LIMIT $ _
OFFICERS ARE: EXCL i EL DISEASE -EA EMPLOYEE $
I OTHER
DESCRIPTION OF OPERATYONSILOCAT[ONSI11EHiCLES/SPECIAL ITEMS
CERTIFICATE HOLDER IS ADDL INSURED PER CG2010; 10 DAY NOTICE
FOR NON PAYMENT PREMIUM
CITY OF SAN JUAN CAPISTRANO
CAPISTRANO VALLEY WATER DIST
32400 PASEO ADELANTO
SAN JUAN CAPISTRACA 92675
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON T11 )ZOMPANY, frY AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTA
Helen Lvnn 1114 A
POLICY NUMBER: 72UUCZP4935 COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURE® - OWNERS. LESSEES OR
CONTRACTORS (FORM B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL. LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization: CITY OF SAN JUAN CAPISTRANO, CAPISTRANO VALLEY
WATER GIST
(If no entry appears above, the information required to complete this endorsement will be shown in the Dec-
larations as applicable to this endorsement.)
WHO IS AN INSURED (Section II) 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 ongoing operations performed for that
insured.
CG 20 10 10 93 Copyright, Insurance Services Office, Inc. 1993
CULBERTSON, ADAMS &_ASSOCIATI S
PLANNING CONSULTANTS
Fax Transmittal
DATE, fuly iii, 1999 TIME SENT. 2:30 PM_
Dawn M_ Schanderl
Deputy City Clerk
City of San Juan Capistrano
FROM: Kevin Culbertson
SUBJECT: Certificates of Insurance
FAX NUMBER„
TOTAL PAGES FAXEID
TO: (949) 493--1053
FROM- (949) 581-3599
1
in response to your letter dated July 27, 1999 regarding renewal of certificates of insurance with
regard to our work on the PMaar bon cif Fnvir. Vital D09i _ in SuPP )_ oL an Applicat�
Io Appropriae r Fermi I am advised by our insurance agent that such certificates were
mailed to the City the week of July 19 and should now be in your possession.. If such is not the case,
please call me at (949) 581--2888 and I will arrange for replacements to be forwarded -
Thank you for your attention to this matter! -
The in, formation contained in this facsimile i_r privileged and confidential information intended only for the use of the
reripiernt(s) named above- lfyou are not the recipient(s) shown above, you are hereby notified that any copying of
this communication or dissemination of distribution of this material to anyone other than the recipient(s) is strictly
prohibited. If you have received this communication in error, please notify us by telephone IMMEDIATELY and
return the original message to us at the address below, via U.S. 1'040a1 Services.