1998-0918_CULBERTSON, ADAMS, & ASSOCIATES_InsuranceUU/18/U8 1.5:51 i~AX 114 bN13�U9 ULIL13LKl iUIN ADAMb
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CULURTSON, ADAms &Ac-SOCIA'I'LS
PLANNING CONSULTANTS
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FROM, _(949),51-3594 .
`1'II[S DOCUMENT CONTAINS _ _ PAGES INCLUDING THIS COVER PAGE.
The Information contained in this facsimile is privileged and confidential information intended
only for the use of the recipient(s) named above. If you are not the recipients) shown above, you
are hereby notified that any copying of this communication or dissemination or distribution of
this material to anyone other than the recipient(s) is strictly prohibited. If you have received this
communication in error, Tease notify us by telephone IMMEDIATFI.,Y and return the original
message tr) us at the address below, via U.S. Postal Services.
85 ARGONAUT, SUJTE 220 • AI.TSO V11 --J0, CALIFORNIA 92656 • (949) 581 2888 . FAX (949) 581-3599
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453 1115
PRODUCER
.ALLIED BROKERS/
YEARGIN INSURANCE
ONE TECHNOLOGY #J729
IRVINE CA 92718
INSURED
CULBERTSON, ADAMS & ASSOC INC
85 ARGONAUT #220
ALISO VIEJO CA 92656
9/18/98
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
COMPANY
€
f POLICY NUMBER
POLICY EFFECTIVE JPOLICY EXPIRATION
DATE (MMMD)YY1 DATE (MMIDDIYY) LIMITS
GENERAL
A
HARTFORD FIRE
,INSURE'` C�E
CO
COMPANY
PRODUCTS - COMP/OP AGG $1,000,000
CLAIMS MADE OCCUR
_W.
PERSONAL & ADV INJURY $1,000,000
COMPANY
EACH OCCURRENCE $1,000, 0 0_0
8
f"}
FIRE DAMAGE (Any one fire] ' $ 300,000
COMPANY
MED EXP (Any one person) $ 10,000
AUTOMOBILE LIABILITY
—n
D
08/01/98 08/01/99 1,000,000
ANY AUTO
r:.7
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE*OLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTu4O WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 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
€
f POLICY NUMBER
POLICY EFFECTIVE JPOLICY EXPIRATION
DATE (MMMD)YY1 DATE (MMIDDIYY) LIMITS
GENERAL
LIABILITY
7 2 UUCZ P 4 9 3 5
8/01/98 8/ 01 / 9 9 GENERAL AGGREGATE $1,000,000
X
COMMERCIAL GENERAL LIABILITY
PRODUCTS - COMP/OP AGG $1,000,000
CLAIMS MADE OCCUR
_W.
PERSONAL & ADV INJURY $1,000,000
OWNER'S & CONTRACTOR'S PROT
EACH OCCURRENCE $1,000, 0 0_0
FIRE DAMAGE (Any one fire] ' $ 300,000
MED EXP (Any one person) $ 10,000
AUTOMOBILE LIABILITY
—n
7 2 UUC Z P 4 9 3 5
08/01/98 08/01/99 1,000,000
ANY AUTO
COMBINED SINGLE LIMIT $1 , 0 0 O , 0 0 0
ALL OWNED AUTOS BODILY INJURY $
SCHEDULED AUTOS (Per person)
X HIRED AUTOS
BODILY INJURY $
X NON -OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
f � 3
GARAGE LIABILITY ( AUTO ONLY • EA ACCIDENT S
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT: $
AGGREGATE $
EXCESS LIABILITY 7 2 XHUXM6 4 0 6- 09/10/98 0 9/ 10 / 9 9 EACH OccuRRENCE$1 , 0 0 0, 0 0 0
X UMBRELLA FORM AGGREGATE _ S
OTHER THAN UMBRELLA FORM $
WORKERS COMPENSATION AND W STATU-
EMPLOYFJIS' iIABELITY TORY LIMITS ER
EL EACH ACCIDENT C $
THE t?EIOPRIETOR! ;} INCL EL DISEASE -POLICY LIMIT S
PARTNERSIEXECUTIVE
OFFICERS ARE: EXCL
I EL DISEASE -EA EMPLOYEE ? $
i OTHER
DESCRIPTION OF OPERATIONSIE.00ATtONSNEHICLESISPECIAL ITEMS
ADD'L INSURED: THE CITY AND THE WATER DISTRICT, ITS ELECTED OR APPOINTED
OFFICERS,EMPLOYEES & VOLUNTEERS
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
CITY OF SAN JUAN CAPISTRANO EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL—ENDEAV$R— MAIL
CAP I STRANO VALLEY WATER DIST 3 0 DAYS WRITFEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
32400 PASEO ADELANTO �,a eBLIe TION ®R I IABI�+T
SAN JUAN CAP I S TRANO CA 92675
Ir+INIa,
J
VWA
M
LIAi1ILrY" Y END0MEMMNT
CITY OF SAN 3VAN C"IS'MANO
CApLSTRANO VALLEY WATER DISTRICT
32400 Paseo Adelanta
San Juan Capistrano, California 92675
A TN:
PQLI *Y
Hartford Fire PolicyNumer 7��T c`ZE 935
1 � cc�pzuy datsesncutEffectiveDate Au o u s t cl A R
2. pnlicy�l'erm iyrma) °
Ct ZUEr son, dams & ssoc, Inc.
3. Namcalnsured rgorkaut Aliso v a e
4. AddressoiNamedlnsurcd -
S • Limit of Liability Any Onv occuk== dAggx agates i , 0 00 , 0 0
General Liability Ag;egatc (Check one:)
Applies "pet�.3a+� Dieu
Is twice the occurrence limit
5. Deductible or Self-lusured Retention (Nil uttless otherwise specified):
7. Coverage is equivalent to:
Comprehensive General Liability form GL0002 (Ulm) CGO00I 10 9 3 )
Commercial General Liability,,dgdms-made" farm CGO002
S. Bodily Injury and Property Damage Coverage is:
"claims -made"
"occurrence"
if claims made, the retroactive date is
B.
'Phis endorsement is issued in consideration of the policy premium. Notwithstanding any inconsistent statement in the policy to which this
endorsement is attached or any other endorsement attached thereto, it is agreed as follows:
l . 1NSUR.ED. The City and the Water I3istriet, its elected or appointed Officers, officials,activities sloeryfees and volunteers arc
orrned by or on b ehaif
included as insureds with regard to damages and defense of claims arising from; ( c remises owrned, leased or
of the Named Insured, (b) projects aid completed operations of the Named Insured, or () p
used by the Named insured.
2, CONTRXl6'(3TION NOT REQUIRE. As respects: (a) work performed by the Named Insured for or ora behalf of the
City, or (b) projects sold by the Named insured to the City; or (c) premises leased by the Named Insured from. the City,
the it3;UMCC afforded by this policy shall be primary insurance as respects the City, its elected or appointed officers,
officials, employees or volunteers; or staa�d in cul un other
chain of coverage excess of the Named lnsured's scheduled
i
not cantnbute w
other
underlying primacy coverage. in either event, any insurance maintained by the City, its elected or appointedofficers, officials, employees or volunteers shall be in access of this insurance and shall hit tiw
3. SCOPE OF COVERAGE. Ibis policy, if primary, affords coverage at least as broad as:
Comprehensive General Liability Insurance and
(I) Insurance Service$ Office form number GL0002 (Ed. Il73), endotsezaer�
Insurance Services Office form nutaber OL 404 Broad Fora) Comprehensive Gener'a'l Liability
or,
(x) Insurance Services Office Commercial General Liability Ctrvr.xage, "occMence" form CG0001 or "claims -
made" fom 000002; or,
1 d LV0988 6V6 �:# NGS1«d38` no Hod --j WVZC : 0 t 666t—St-6
If excess, affords coverage which is at least as broad as the primary 11uw wo fo=s refemneed in the precedinC
��} Sectiocsc (1) and (2).
'Tile
IN fEItE,ST. insurance afforded by this policy applies sepw&Uly to each insured who is
�. SEVEitASII,i�Y OI`
seeking coverage or agai a whom a clauu is Made or a suit is brought, except withrespect to the Cacapavys limit of
o.
liability-
S. pRO VISIONS REGA"ING THE g+iSUpED'S DUTIES AFMR ACCded to ID Z d the Water Y Wum i elected
0mP1d
wish provisions
repordug of the policy shah not affect aovczagePra`i�
or appointO omcem officials, =Plnyees or volunteers.
4. CANCELLATION NOTICT. Mt k=2400 afforded by osis policy s}�a11 not be mPeaded, voided, patxlled, reduced
ec
in coveaago or !hauls except after thirty (3 Q) days' Frio' wng= notice by certified mail ret= receipt rr Fcged has been
given to the City. Such notice shalt be addressed as shown in the heading
oti this exidanement:
� �� ►1( .. J� ::fir a � eft ' • � � -
lacidents and chums are to be reported to the insumr of
A.TTI`i:...... (Dquanew.
(Title) . .
Yeargin Insurance
One Technology J729
(Street Address)
Irvine Ca 92618
(City) (Sfax} (Z.ip code)
(949)453 1115
(Telephone)
D.
Helen Lynn (prbxe"o name watma u that 1 have authority to bind the below listed
[' m st lure herEora da so biztd this cvtapanY-
Insuranca Company and by y '�
/r) .1%_
0 A. TGNDEsENTAB
S�ORZ
(original sigaamrc required on cndorserncat fiirnighul to the City)
Yeargin Ins Agency TITLE
ORGANIZATION, 949 453 1115
ADD1tESS:
One Technology J729 Irvi 'TELEPHONE:
Z -d LV098USSV6 Z#x NOSIUMIno WobA WVSS' 0 t 8661—?L-6
OS/26/98 16:55 FAX 714 58.13599 CULBERTSON,ADAMS
LIABILITY ENDORSEMENT
CITY OF SAN JUAN CAPISTRANO
CAPISTItANO VALLEY WATER DISTRICT
32400 Paseo Adelanto
San Juan Capistrano, California 92675
ATTN:
A. I'OLICZ' CNk'4It. pTDN
1. InsuranceCompany Hartford Fire I
Fodor.
2. ParnedI cured. Cia er son, (dams -& Assoc, In
3, Naraedlrisured rgonaut 20, Aliso
4. AddressofNamedlnsured
5 Limit of Liability Any One Occurrence/Aggregate $1
1a003/006
)~ndorsement#
policyNutrilier72JL C Z P 4 9 3 5
General Liability Aggregate (Check one:)
Applies accurre
Is twice the occurrence limit
5. Deductible or Self -Insured Retention (Nil unless otherwise specified): $n I-1
7. Coverage is equivalent to:
Comprehensive General Liability form GLo002 (Ed 1113) C G 0 0 0 1 (i 0 9 3)
Commercial General Liability "clauns-made" form CGO002
g, Bodily Injury and Property Damage Coverage is:
"claims -made"
"occurrence"
if claims -made, the retroactive date is
B. POLICY AIVIENOMENTS
on of the policy premium. Notwithstanding any inconsistent statement in the policy to which this
This endorsement is issued in considerati
endorsement is attached or any other endorsement attached thereto, it is agreed as follows:
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 arising £rom; (a) activities performed bby'odr, aced on if
of the Named Insured, (b) projects and completed operations of the Named Insured, or (c) premises
or
used by the Named Insured.
(a) work performed by the Named Insured for or on behalf of the
2, CONTRIBUTIUI't NOT REQUIRED. As respects:
Ci or @) projects sold by the Named Insured to the City; or (c} premises leased by the Named Insured from the City,
'insurance as respects the City, its elected or appointed officers,
the insurance afforded by this policy shall be primary
officials, employees or volunteers; or stand in an unbroken chain of coverage excess of the Namedelected !s appointed
underlying primary coverage. In either event, any sured!s scheduled
outer insurance maintained by r5'� cted
officers, officials, employees or volunteers shall be in excess of this insurance and shall not contribute with it.
SCOPE OF COVERAGE. This policy, if primary, affords coverage at least as broad as:
(1} Insurance Services Office form number GLOoo2 (Ed. 1173), Comprehensive General Liability Insurance and
04 Broad Form Comprehensive General Liability endorsement;
Insurance Services office form number GLfl4
or,
(2) Insurance Services Office Commercial General Liability Coverage, „occurrence" form CG0001 or "claims -
made" form CGO002; or,
08/26/98 16:57 FAX 714 5813599 CULBER'TSON ADAMS
IM 004/006
(3) if excess, affords coverage which is at least as broad as the pritmary insurance forms referenced in the preceding
sections (1) and (2).
SEyEggD,rry Ol~ INTEREST. The insurance afforded by this policy applies separately to each insured who is
4. seeking coverage or against whom 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.
b. CANCELLATION NOTICE. The insurance afforded b �� policyby ceertifi d mail rree�n receipptt requeested has been
in coverage or limits except reduced
after thirty (30) days prior
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 ecn
(Company)
One Technology J'729
(Street Address)
Irvine Ca 92618
(City) (State) (Zip code)
(949)453 1115
(Telephone)
D. G AT ENSURE IJ O iZ DRE
p IN
Helen Lynn (print/type name), warrant that I have authority to bind the below listed
I.
insurance company and by my signature hereon do so bind this company.
SIGNATURE OF A�JTHORiZED OPRESENTATIVE
(Original signature required on endorsement furnished to the City)
Yeargin Ins Agency TITLE ORGANIZATION,949 453 1115
ADDRESS:
One Technoiogy J'729 Irvi TELEPHONE: