1993-0907_ORANGE COUNTY HEAD START_Insurance Certificate (General) ACORDM CERTIFICA) t OF LIABILITY INSURANCE °o9Eioy 6 Y)
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Caldwell Ins. Agency Inc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
15935 Whittier Blvd ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Whittier, CA 90603-2567 COMPANIES AFFORDING COVERAGE
COMPANY
A Great American Ins Co.
INSURED COMPANY
Orange County Head Start, Inc B Co . C
1440 E First Street Ste.#320 COMPANY
Santa Ana, CA 92701 C
COMPANY
BOH D
:a '. 1 ,. µsq s. r ..,,,,._L •,
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 TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR DATE(MM/DD/YY) DATE(MM/DD/YY)
A GENERAL LIABILITY PAC2000372 08/25/96 08/25/97 GENERAL AGGREGATE $ 2,000,000
X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG $ 1,000,000
CLAIMS MADE X OCCUR PERSONAL&ADV INJURY $ 1,000,000
OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ 1,000,000
FIRE DAMAGE(Any one fire) $ 200,000
MED EXP(Any one person) $ 5,000
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
ANY AUTO
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
HIRED AUTOS BODILY INJURY
NON-OWNED AUTOS (Per accident) $
PROPERTY DAMAGE $
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT $
—
AGGREGATE $
EXCESS LIABILITY EACH OCCURRENCE $
UMBRELLA FORM AGGREGATE $
OTHER THAN UMBRELLA FORM $
WORKERS COMPENSATION ANDI TORY WC ER
STLIIMITMIT S T
EMPLOYERS'LIABILITY
EL EACH ACCIDENT $
THE PROPRIETOR/ INCL EL DISEASE-POLICY LIMIT $
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE $
OTHER T
L
G
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS -C C;--d tV
rri
Certificate holder is added as additional insured with respectst to ,;x r �
premises leased to insured at,32502 Paseo Adelanto,San Juan Capistrano, n: z,z�' co rn
CA 92675 - —o
CERTIFICATE HOLDER CANCELLATION:Ten Day Notice for Non-Payment fOremilewn
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
City Of San Juan Capistrano EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
Attn: Mary 30_DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
324 Paseo Adelanto BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
San Juan Capistrano,CA 92675 OF ANY KIND UPON THaiMPANY, ITS AGENTS OR REPRESENTATIVES.
•AUT'+RIZEp.REPRt/
SENTATIVE i li?..,
/ ,I ���qy' .
- , ACORDrCOR ORATION 1988
•
MEMBERS OF THE CITY COUNCIL
4 COLLENE CAMPBELL
iter‘\At--
%46
�� WYATT HART
L1 �f IAfomvoAAifo GILJONES
• f SIAIIISRIA 1961 CAROLYN NASH
1776 i1 DAVID SWERDLIN
• CITY MANAGER
• GEORGE SCARBOROUGH
August 21, 1996
Mr. Marco T. Pena, Director
Orange County Headstart, Inc.
1440 East First Street, Suite 320
Santa Ana, California 92701
Re: Renewal of General Liability Certificate of Insurance (Lease of City Property/Head Start
Program)
Dear Mr. Pena:
The General Liability Certificate of Insurance, regarding the above-referenced project, is due to
expire on August 25, 1996. In accordance with your agreement, the insurance certificate needs to
be renewed for an additional period of one year. The agreement requires a general liability
endorsement form naming the City of San Juan Capistrano as an additional insured. I have included
a City approved endorsement form to submit to your insurance company; however, your insurance
company may provide their own endorsement form.
Please forward the updated certificates and the endorsement form to the City, attention City Clerk's
office, by September 6, 1996.
If you have any questions, please contact me at (714) 443-6310.
Thank you for your cooperation. ,y
Very truly yours, /- q -96 di/42_ •
A_//n
Iva AftaA-
atotph .
Dawn M. Schanderl
Deputy City Clerk
Enclosure
cc: Cheryl Johnson, City Clerk
Mary Laub, Management Analyst II
32400 PASEO ADELANTO, SAN JUAN CAPISTRANO, CALIFORNIA 92675 • (714) 493-1171