1997-1007_THE HUNT CLUB_Insurance Certificate 1 STATE P.O. BOX 420807,SAN FRANCISCO,CA 94142.0807
COMPENSATION
INSURANCE
/
FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE DO yob
SEPTEMBER 19, 1997 POLICY NUMBER: 1476457 — 97
CERTIFICATE EXPIRES:
T
CITY OF SAN JUAN
ATTENTION: KATHY GRONAU
3.7.40C1 P`1SEO ADEL1,NTO
SAN JUAN CAPISTRANO CALIFORNIA 92E76 JOB: RLL OPERATTONS
This is to certity that we have issued a valid Workers' Compensation insurance policy in a form approved by the California
Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon lijdays'advance written notice to the employer.
We will also give you�days'advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the
policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document witn
respect to which this certificate of insurance 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.
A'CZJZfeZt..4 %.
AUTHORIZED REPRESENTATIVE PRESIDENT
EMPLOYER' S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,0@0,004' PER OCCURRENCE.
ENDORSEMENT #24115 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE
09/19/97 IS ATTACHED TO AND FORMS A PART OF THIS POLICY.
NAME OF ADDITIONAL INSURED: CITY OF SAN JUAN
ENDORSEMENT 3#2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE
09/19/97 TS ATTACHED TO AND FORMS A PART OF THIS POLICY.
EMPLOYER
f—
PRLILUS ENGINEERING, INC.
P. O. PDX E216 •
ANAHEIM CALIFORNIA 92216
THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND scar,ort;z inEV.3 96
":10„,„.mtnwhii: •.: isCUE DATE tMMDDAY)
4E; 9'19,97
-
PRGDUCEr, THIS CIIRTIFICATE18ISSUED AS A MATTER Ot NFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE
DOES NOT AMEND.EXTEND OR ALTER THE COvER,AGE AFFORDED BY THE
POLICIES BELOW
The Rule Company, Inc.
COMPANIES AFFORDING COVERAGE
P.O. Box 7072
CONIPANY
Pasadena, CA 91109 LETIER A Travelers Indemnity Co. of Ili.
COMPANY
D
INSURED LETTER
COMPANY
LETTER ,••••
Paulus Engineering, Inc. COMPANY
P.O. Box 5216 LETTER D
COMPANY
Anaheim CA 92816-0
LETTER E
THIS IS TO CERTIFY THAT THE POLICIES OP INSURANCE LISTED RCLOw HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE POR THE POLICY PERIOD
DIDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITH1N oy ANY CONTRACT OR OTHER DOCUMENT WITH RE spit?TO IA HIGH THIS
CEILIDH C ATP MAY 10 ISSLTD01 mAY PER rA/N,TILE INsVRANCF,AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALI.THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO POLICY EFF. pOLICy Exp.
TYPE OF INSLRANCE POLICY NLM BIER LIMITS
_TR DATE(MMiDONYI DATE(MMIDDNY)
A GENERAL LIABILITY C0331K0754 5/01/97 5/01/98 GENERAL A CrGRECATE 2000000
X COM‘I.GENERAL LIABILITY PROD-COMP'OP AGG. 2000000
CLAIMS MADE CTIOCC. PERS.&ADY.INJURY 1000000
X OWNERS&CONTRACT'S PROT EACH OCCLRRENCE 1000000
FELE DAAMAGE(CHAe Etre) 50000
MED.EXP.tOne Per) 5000
A AUTOMOBILE LIABILITY 810331K0729 5/01/97 5101/98 COMBINED SINGLE 1000000
ANY ALTO LIMIT
ALL OWNTll AL,* BODILY INJURY
SCHEDULED AUT( iPsrp•or....1
x WEED At T(. BODILY INJURY
,_./..NoN-OwNED ALTOS
CARACKIJARUATY
PROPERTY DAMAGE
A EXCESS LIABILITY CUP331K6132 7/22;97 5/01/92 EACH OCCURRENCE 4000000
x UNIRRELLA FORM AGGREGATE 4000000
OTHER THAN UMBRELLA FORM . .. ..„ . „ . .
. .. „.. ..• .• •:
STATUTORY LI‘IITS •
WORKERS'COMPENSATION EACH ACCIDENT
AND DLSBASE-POLICT LLMII
EMPLOYER'S LIABILITY DISE ASELCA CH EMI'.
OTHER
DESCRIPTION OF OPERATIONS,LOC A TIONSNEHICLES/SFECIAL ITEMS
RE: All operations of the named insured for the certificate holder.
Endorsement CG2010 attached.
SHOVLD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL EINIMM,PeR.PEr
MAIL :In DAYS WRITTEN NOTICE TO TILE CERTIFICATE HOLDER NAMED TO THE
City of San Juan
'", LEFT • •
Attn: Kathy Gronau . •... • - • . .
32400 Paseo Adelanto
AL/THORIIED REPRESENTATIVE
San Juan Capistrano, CA 92675 (.
•
111
STATE P.O. BOX 420807,SAN FRANCISCO,CA 94142-0807
COMPENSATION
INSURANCE
FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
SEc'TEMgER t J, 1997 POLICY NUMBER: 1476457 — 97
CERTIFICATE EXPIRES:
CITY OF SAN JUAN
ATTENTION: KATHY GRONAU
:2400 PASEO ADELANTO
GA` JUAN CAPISTRANO CALIFORNIA 92E7G JCq: ALL OPERATIONS
l._
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California
Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon t days'advance written notice to the employer,
We will also give you days'advance notice should this policy be cancelled prior to its normal expiration.
XX
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the
policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document with
respect to which this certificate of insurance 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.
77:2—e- 11-Z Z t2,
AuTHoFtIZEo REPRESENTATNE PQESiOENT
EMPLOYER' S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1, 000,000 PER OCCURRENCE.
ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE
09/19/37 IS ATTACHED TO AND FORMS A PART OF THIS POLICY.
NAME OF ADDITIONAL INSURED: CITY OF SAN JUAN
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE —
09/I9/37 IS ATTACHED TO AND FORMS A PART OF THIS POLICY.
EMPLOYER
PAULUS ENGINEERING, INC.
P.0. BOX 6216
ANAHEIM CALIFORNIA 92816
THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND SC1F 10262{REV.3-9
POLICY NUMBER CO331K075-3 COMMERCIAL GENERAL LIABILITY
CG 20 10 11 65
Paulus Engineering. Inc.
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
SCHEDULE
Name of Person or Organization:
City of San Juan Capistrano RE: All operations of the named insured for the
32400 Paseo Adelanto certificate holder.
San Juan Capistrano, CA 92675-3603
(If no entry appears above, information required to complete this endorsement 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 work"for that insured
by or for you.
CG 20 10 11 85 Copyright, Insurance Services Office, Inc., 1984