1998-0925_CULBERTSON, ADAMS, & ASSOCIATES_Certificate of InsuranceHu. �� � �
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8/01/98 8/01/99
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PRODUCTS . COMPlOP AGG
09/25/98
PRODUCER
THIS CERTIFICATE IS ISSUED AS A
MATTER OF INFORMATION
ALLIED BROKERS/
ONLY AND CONFERS NO RIGHTS
UPON THE CERTIFICATE
EACH OCCURRENCE
HOLDER.
THIS CERTIFICATE DOES
NOT AMEND, EXTEND OR
YEARGIN INSURANCE
ALTER THE COVERAGE AFFORDED
BY THE POLICIES BELOW.
ONE TECHNOLOGY #J729
MED EXP (Any one person)
COMPANIES AFFORDING COVERAGE
IRVINE
CA 92618 COMPANY
:
I COMBINED SINGLE LIMIT
1,000,000
$
A
..................._—
HARTFORD FIRE
INSURANCE CO
INSURED....
COMPANY
....._......_,_.,._...._
CULBERTSON, ADAMS &
ASSOC INC
GOLDEN EAGLE INS
CORP
COMPANY
85 ARGONAUT #220
C
AL I S O V I E JO
CA 92656 CO ANY
�
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.
€ LTo ii D. IN
TYPE OF SURANCE POLICY NUMBER
POLICY EFFECTIVE POLICY EXPIRATION] LIMITS
DATE (MMIDDIYY) , DATE (MM/DDlYY)
GENERAL LIABILITY 72U UCZ P4 9 3 5
8/01/98 8/01/99
GENERAL AGGREGATE
$1,000,000
COMMERCIAL GENERAL LIABILITY
-----_-....-
PRODUCTS . COMPlOP AGG
�---._._..._—_.
$ 1 , 0 0 0 , 0 O 0
CLAIMS MADE C OCCUR .
PERSONAL & ADV INJURY
$1,000, 000
OWNER'S & CONTRACTOR'S PROTE
EACH OCCURRENCE
S1,000, 000
FIRE DAMAGE (Any one fire)
$ 3 0 0 0 0 0
^$
MED EXP (Any one person)
10 , 0 o 0
AUTOMOBILE LIABILITY ' 72UUCZP4935
Y
08/01/98 1 08/01/99
:
I COMBINED SINGLE LIMIT
1,000,000
$
.AN AUTO
ALL OWNED AUTOS
1 SCHEDULEI) AUTOS.
X `HIRED AUTOS
i� NON -OWNED AUTOS
GARAGE LIABILITY
ANY AUTO
BODILY INJURY $
(Per person)
BODILY INJURY $
(Per accident)
PROPERTY DAMAGE €$
AUTO ONLY - EA ACCIDENT ($[
OTHER THAN AUTO ONLY:
.............................. .........
EXCESS LIABILITY 7 2 XHUXM 6 4 0 6 9/10/98 8/01/99 _EACH OCCURRENCE $1 , 0 co 0 00
X UMBRELLA FORM 1 [ AGGREGATE $
OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND NWC3 8 3 0 2 2 U L '18/31/98 j 8/31/99 X 1 TORYSLIMITS
EMPLOYERS' LIABILITY i - ----
EL EACH ACCIDENT L $1, 0 0 0, 0 0 0
THE PROPRIETOR! -
INCL
PARTNERS/EXECUTIVE ---' EL DISEASE •-._ ICY LIMIT I S 1 , 00 0 , _0 0 0
OFFICERS ARE: X EXCL EL DISEASE -EA EMPLOYEE $1, 000 000
I OTHER
I
fTi
r7CD
DESCRIPTION OF OPERATIONSrLOCATION$NEHICLES/SPECIAL ITEMS
CERTIFICATE HOLDER IS ADDL INSURED PER CG20.0; 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 CA14CEI; O 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 THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
C HL A
POLICY NUMBER: 72UUCZP4935
COMMERCIAL GENERAL LIABILITY
CG 20 10 10 93
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED — OWNERS, LESSEES OR
CONTRACTORS (FORM B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
Name of Person or Organization:
SCHEDULE
CITY OF SAN JUAN CAPISTRANO
CAPISTRANO VALLEY WATER DIST
32400 PASEO ADELANTO
SAN JUAN CAPISTRANO CA 92675
(if no entry appears above, information required to complete this endorse-
ment 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 or organization shown in the Schedule, but only with respect to
liability arising out of your ongoing operations performed for that insured.