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1999-0601_BOYS & GIRLS CLUBS OF CAPISTRANO VALLEY_Insurance Maria Guevara From: Maria Guevara Sent: Friday, April 15, 2005 3:08 PM / To: Karen Crocker J( Subject: Boys & Girls Club �^ A �Y Karen, � \IV- 1 received copy of the w/c that you sent over, I had a copy in our files. I called State Fund and the policy has been cancelled since 1/1/05. 1 added them to the non-compliance list. Thanks for your help, Maria Guevara, Administrative Secretary City of San Juan Capistrano City Clerk Division (949) 443-6309 i tD11110 )ICQBDe CERTIFICAT F LIABILITY INSURA DATE PRODUCER (949)852-0909 FAX ( 852-1131 THIS CERTIFICATE IS UED AS A MATTER OF INFORMATION Milestone Insurance Brokers ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O. Box 19598 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 8 Corporate Park, Ste 130 Irvine, CA 92623-9598 INSURERS AFFORDING COVERAGE NAIC# INSURED Boys & Cirls Clubs of Capistrano Valley msURERA Philadelphia Indemnity Ins. One Via Positiva MSURERB San Juan Capistrano, CA 92675 INSURER C. INSURER D' INSURER E'. COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDINI 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIONLTR INqRN IMMIDDNYI LIMITS GENERAL LIABILITY PHPK098729 11/01/2004 11/01/2005 EACH OCCURRENCE $ 1,000,00 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,000 CLAIMS MADE Fx] OCCUR MED EXP(Any one Person) $ 5,000 A X PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 POLICY D PRO JECT LOC AUTOMOBILE IASUATY PHPK098729 11/01/2004 11/01/2005 COMBINED SINGLE LIMIT X ANY AUTO (Ea accident) $ 1,000,00 ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per Person) $ A X HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per acmdent) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY. AGG $ EXCESS/UMBRELLALIABILITY PHUB037454 11/01/2004 11/01/2005 EACH OCCURRENCE $ 1,000,00 X OCCUR ❑ CLAIMS MADE AGGREGATE $ 1,000,00 A X $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC STATU.EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ If yes,Eesoibe under SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT I $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS City of San Juan Capistrano, its officers, agents and employees are added as additional insured as respects the operations of the Named Insured. Except 10 days notice for non-payment of premium. ERTIFICATE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30" DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, City of San Juan Capistrano BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 32400 Paso Adel anto OFA IND UPON THE INSU R,ITS AGE TS?,P TATIVES. San Juan Capistrano, CA 92675 AUTH R R S r n E ACORD 25(2001/08) OACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend,extend or alter the coverage afforded by the policies listed thereon. ACORD 26(2001/08) 11/11'/2004 10: 32 949-852-11'x+.7.• MILESTONE RISK Mit PAGE 01/05 I i Milestone Risk Management & Insurance Services License 4OB72766 Eight Corporate Park, Suite 130 Irvine , California 92606 5105 800 808- 8458 Fax 949 852 - 1131 949 952-090.0 tt;1ltp.ip4 '10,4::4, .it1Wf Milestone T o : Bonnie Gallacher Company : Boys & Girls Club of Capistrano Valley Fax Number : (949) 240-7308 From : Amanda Steele R e : City of SCJ and Boys and Girls Club of America # of pages : 5 Comments: Please see attached Certificate of Insurance issued on behalf of Boys & Girls Club of America and City of San Juan Capistrano . The original will follow by mail. Please let me know if this is insufficient in any way. Please let me know if you have any questions or need any additional information. Regards, Amanda Steele �1 Processing Coordinator CC: Pacific Service Center (562) 981-8887 U License 4OB72766 11/11/2004 10:32 949-852-11 1 MILESTONE RISK M G PAGE 02/05 .Aggq ,N CERTIFICATE ' LIABILITY INSURANA 11/11/z as TODUCER (949),852-0909 FAX (949)852-1131 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Hlestone Insurance Brokers ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE :1.0. Box 19598 HOLDER,THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 4 Corporate Park, Ste 130 Ervine, CA 92623-9598 INSURERS AFFORDING COVERAGE NAIC# SUREE Boys & Girls Clubs of Capistrano valley INSURERA Philadelphia Indemnity Ins. One Via Positiva INSURER B' San Juan Capistrano, CA 92675 INSURFR C: INSI,IRER D; INSURER E u OVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWRHSTANDINI ANY REgUIREMENT.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 IB SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 3R DD TYPE OF INSURANCE POLICY NUMBER PODGY EFFECTNE POLICY EXPI OIR" LIMITS GENERAL LIABILITY PHPK098729 11/01/2004 11/01/2005 SACH OCCURRENCE a 1'(100,00 x COMMERCIALGENERALLIASILTY DAMAGE TO RENTED -L-100 120 CLAIMS MADE 7 OCCUR MED EXP IAry Rne Ferran) S 5.00( I X PERSONAL A ADV INJURY S 1,000,001 GENERALACGREOATE S 3,000,00 GENL AGGREGATE LIMB APPLIES PER: PRODUCTS-COMRIOP AGG S 1.0001001 POLICY jEa LOC AUTOMOBILE LWMILIIY PHPK093729 11/01/2004 11/01/2005 CONIBINEO SINGLE LIMIT X ANY AUTO Meecddenp 3 1,000,00 ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Por Perron} S X I HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Por oecideM) 4 PROPFRTYDAMAGE S (Per eccldem) GARAGE LIABILITY AUTO ONLY.EAACCIDENJT 5 ANYAUTO OTHER THAN FA ACC 5 AUTO ONLY: AGG S EXCESSIUMIRELLA LIABILITY PHUB037454 11/01/2004 11/01/2005 EACH OCCURRENCE a 1,000,0 X OCCUR 0CLAIMS MADE, AGGREGATE 5 1,000,0 X s DEDUCTIBLE B AFTF,NTION 7 .T WORNER5 COMPENSATION AND PRBM`1 .v D R _..,_-„ EMPLOYERS'LIABMTY E.L.EACH ACCIDENT S ANYPRIVIVEM ER EXCLUDEDxFCU7NF. OFFICER/MEMBER EXCLUOE07 E.L.DISEASE-EA EMPLOYEE S If yyrr Eavcribe lrtlMr SPELIIAL PROVISIONS balm E,I..DISEASE-POILMY LIMB f OTHER SCRIPTION OF OPERATIONS/LOGTION91 VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS ty of San Juan Capistrano, its officers, agents and employees are added as additional insured as spects the operations of the Named Insured. Sxcept 10 days notice for non-payment of premium. iRIIFICATEODE —CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE 199UING INRURSR WILL ENDEAVOR TO MAIL 30* DAYS W Rrrrm NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, City of San Juan Capistrano BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 32400 Paso Adelanto OFA D UPON THE INSURER,ITS AGENTS O REPRESSNTATNES. San Juan Capistrano, CA 92675 AUTHo E E ESENTATIVE � J4� Sic ORD 25(2001108) MACORD CORPORATION 19 _r 11;1 /2004 10: 32 949-852-1 MILESTONE RISK VG PAGE 03/05 IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(les) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance an the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. 3RD 25(2001108) iziiACORP,. CERTIFICAF LIABILITY INSURA E io004 PRODUCER (949)852-0909 FAX (949)852-1131 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Milestone Insurance Brokers ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O. Box 19398 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 8 Corporate Park, Ste 130 Irvine, CA 92623-9598 INSURERS AFFORDING COVERAGE NAIC# INSURED Boys & Girls Clubs of-Capistrano Valley INSURER A: Philadelphia Indemnity Ins. One Via Positive INSURER B: San Juan Capistrano, CA 92675 INSURER C: INSURER D. NSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTW ITHSTANDINI 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMBS DATE NWOWYI DATE IMMIDWY1 GENERAL LIABILITY PHPK098729 11/01/2004 11/01/200S EACH OCCURRENCE $ 1,000,00 X I COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,00 CLAIMS MADE F5q OCCUR MED EXP(Any one person) $ 5,00 A PERSONAL&ADV INJURY $ 1,000,00( GENERAL AGGREGATE $ 3,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 1,000,00 POLICY PRO LOC JECT AUTOMOBILE UABILMY PHPK098729 11/01/2004 11/01/2005 COMBINED SINGLE LIMIT X ANY AUTO (Ea accident) $ 1,000,00( ALL OWNED AUTOS BODILY INJURY $ A SCHEDULEDAUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ P AUTO ONLY: AGO $ EXCESSIUMBRELLA LIABILITY PHUB0374S4 11/01/2004 11/01/2005 EACH OCCURRENCE $ 1,000,00 X OCCUR FICLAIMS MADE AGGREGATE $ 1,000,00 A $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC STATU- OTH- EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICEWMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ U yes,describe under -- SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIP`D N OF OPERATIONS I UOCATMNS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS ity of San Juan Capistrano, its officers, agents and employees are added as additional insured as aspects the operations of the Named Insured. lo Except 10 days notice for non-payment of premium. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30* DAYS WRRIEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, City of San Juan Capistrano BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LABILITY 32400 Paso Adelanto OF ANY KIN 21 PON THE INSURER ITS AGE S OR REPRESENTATIVES. San Juan Capistrano, CA 92675 AUTHORIZED FIEPPOEHENTATIV � -� ACORD 25(2001/08) ®ACORD CORPORATI 1988 � s IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer,and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001/08) ACO D CERTIFICA OF LIABILITY INSURANO OPID $ DATE(MM/OD YYYY) BOYS&-9 05 05/06/05 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Chapman & Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE License #0522024 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P. O. Box 5455 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Pasadena CA 91117-0455 Phone: 626-405-8031 Fax: 626-405-0585 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A'. Ales, North America Ins CO INSURER 8: BO s&Girls Club of Capistrano Valley INSURER C. One Via Positiva INSURER D: San Juan Capistrano CA 92675 INSURER E'. COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER DARATION TEYEFFECTIVE I MMIDD/YY PDATE MMIOLICY UD/ YY LIMITS GENERAL LIABILITY EACH OCCURRENCE s COMMERCIAL GENERAL LIABILITY PREMISES(Ea oaurence) $ CLAIMS MADE OCCUR MED EXP(Any one person) $ PERSONAL$ADV INJURY $ GENERAL AGGREGATE $ GENL AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGO $ POLICY�� PRO- LOC ECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea eccitlenq ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per soodent) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ❑ CLAIMS MADE I ' AGGREGATE s $ DEDUCTIBLE \ - ( $ RETENTION $ $ WORKERS COMPENSATION AND TORY LIMITS ER _ EMPLOYERS'LIABILITY AANY PROPRIEIOWPARTNEHrEXEGUTWE WC1003364 01/01/05 01/Dl/06 EL EACH ACCIDENT $ 1000000 ' � -- -------- -- - ------- --- OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 1000000 Use.tlesonbe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $1000000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS *******CERTIFICATE OF INSURANCE IS ISSUED AS EVIDENCE OF COVERAGE ONLY****** CERTIFICATE HOLDER CANCELLATION CITYSAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN City of San Juan Capistrano NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL City Clark's Office IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Linda Evans 32400 Paseo Adelanto REPRESENTATIVES. San Juan Capitrano CA 92675 AUT DREPRE ACORD 25(2001/08) 0 ACORD CORPORATION 1988 SG THOLDER COPY STATE P.O. BOX 807, SAN FRANCISCO,CA 94142-0807 COMPENSATION INSURANCE FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 01-01-2005 GROUP: POLICY NUMBER: 1381364-2005 CERTIFICATE ID: 3 CERTIFICATE EXPIRES: 01-011-2006 01-01-2005/01-01-2006 CITY OF SAN JUAN CAPISTRANO SG JOB: AFTER SCHOOL RECREATION ATTN CITY CLERK'S OFFICE PROGRAMS REAL PROPERTY 32400 PASEO ADELANTO LEASE AGREEMENT SAN JUAN CAPISTRANO CA 92675 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 Jodays' advance written notice to the employer. We will also give you 10 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 with respect to which this certificate of insurance-maybe issued or may pertain, the insurance afforded by the policies described herein is subject to all the terms; exclusions and conditions of such policies. AUTHORIZED REPRESENTATIVE PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000.00 PER OCCURRENCE. EMPLOYER / LEGAL NAME BOYS AND GIRLS CLUB OF CAPISTRANO BOYS AND GIRLS CLUB OF CAPISTRANO VALLEY VALLEY - (A NON-PROFIT PUBLIC,BENEFIT CORP) 1 VIA POSITIVA SAN JUAN CAPO CA 92675 (REV.3-03) PRINTED: 12/17/2004 P0408 THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND �CIF 1026', 32400 PASEO ADELANTO SAN JUAN CAPISTRANO,CA 92675 IBfBAXBAAifX MEMBERS OF THE CRY COUNCIL (949)493-1171 fSXBBU3XEX I I96I SAM ALLEVATO (949)493-1053 FAx 1776 DIANE L BATNGATE www.sanjuancapistrano.org WYATT KART JOE DAVIDD M.M.SWERDLIN December 16, 2004 Boys & Girls Club of Capistrano Valley One Via Positiva San Juan Capistrano, CA 92657 RE: Compliance with Insurance Reguirements — After School Recreation Program/Property Lease The following insurance document is due to expire: J Workers Compensation Certificate 1/1/2005 �OA, Please submit updated documentation to the City of San Juan Capistrano, attention City Clerk's office*de. 32400 Paseo Adelanto, San Juan Capistrano, CA 92675 by the above expiratione any questions, please contact me at (949) 443-6309. cc: Karen Crocker, Community Services Manager ,.0 San Juan Capistrano: Preserving the Past to Enhance the Future ----------------- SG STA oICVHOLDER COPY oOMP�NS^TiON . ' P.O.TE BOX 807; SAf'! FRANCISCO;CA 94142-0867 N S U Fk AIN G`E ' I�U N D CERTIFICATE OF WORPEERS` COMPENSATION INSURANCE 113S6E DATE: 01-01-2005 ,. GROUP:::.. F• PO4lCY-NUM6ER' IY 38f364 2Q0ia a; CERTIFICATE ID:, CERTIFICATE EXPIRESdt 07-2006 ,a _ '0l 01-X005/09 01+2d0& - CITy AF SANJUANGAf,ISTRAFIO SG ATTN CITY CLERK'S OFFfCE < : .JOB: AFT" SCR6(j , RE0,)Ik (TION 32400 PA-SE0 AOELAf TO- PRdGRAMS REA14ihI�,,pT' �J''CA'PJ'•ST RANb';GA t Ji56 � REE&[ft AM'JUAwTY 265 zw Tgi3 is"SO certlf khat We have lssus4, a v id �.t al U�'brk ers CgmPas}aUprY-,msuraryee pa[fcY iry a`,` otitn appr�bved bap (ae , r >, Cal]iohnla I,nSf�ranGe Grommissroner to the omplo"? iarhed bell5w hart t�Ib poN'cy genpd intlic' w. a ' 7fi,s ofe Is not subJedY'ab cancellation b `6 m p Y P Yy Y�'the.kPiiPitl a$ aDr days ativapoiw wrif#�H'nbYtc �h� r�mpldysr x - t• r r r t will 11so give ou .; 9 n Y ib, ays apvan¢e �e sha c . , -, '�,. Il� ht�l3�nh�y-be oanGelled - �: � ,.e r4 , rmalr'd:KRrraSraft � .s • � r ThI§,c�£iiate; f r stars o� is Of ' tQtjnsPr� p41iY ar9ks nesf a�enm ,e etsncir alker tfie� ape po11Ga§tliste heretP NthscandP A p;rat Diren arm oi_condixFFon:pf anq ab ttgx or'ra;her tliocuhrept n i +atwitfhyespe¢t t¢;w.h�¢h L poP Glk� SYpS[;tvhed hare�tn�i`iS3'gseurbf�it ~4F oe w+nap,. -,'isu6di ro»r iYMtiydit&wns ';Yn$' mrttrandtl5raid p"f suGr pbdistE kXr �� kk..✓✓ '4 'NA a R Y 6 e Az a. �7%, AUY%0RI7cED REPRE$ENTAT,IUE a 1 sr a k d ., ov ii PFEEID.ENT "" r Y h 7 at ir, EM L'Yd1ER'S t„3/�H�iI1'Y.•I.PMIT INiGLO'ISIN ✓AEF EIS�f'r' p 75 m g1,�003 1Y�0`Go PEk�O � s tl t4 I ,ill 1Y� - �t ' s x r �'� rte• -4 e r.�i IS i1a _; h rry 4 ,, yr x Oxy id � �j q c� tn4 v 4 t 'P, ']^ i l t � q;{ 'P' r, c F :� n '.."�[3 .xti"� It �� x ♦ .. SRI, s v� �R qM: a ' _p 34r qhs rTK*�M� d��i �"\4 � a d w � rt �Yrti omv� i.�r \� v � s Aaa:5 r 6�Jv•' ° d ) r$ a h '3n ya M i �Id.� �� '' ` i ✓< r_ � U l,rs � �--! Y .l^� {�h"F.' 4Y-,•^�1 �"�� -'. 2 !w i F I +n t ,�2rr" ➢ rA„ y3 e 1 i � '�, r&� R W AIM 'A' '✓ 't „�+ " y SE fiw '4 r x'a y i-ta4�Ai. 1VAME� w —"'+ q �"�' �i m n IbI aM, wti tit tW I N�: Altaklt� r X0#"5 Rf L5 R �6k n J , a ` CvA yNON RRdFt '}�dInw6F q'i Maria Guevara From: Karen Crocker Sent: Tuesday, April 05, 2005 12:25 PM To: Maria Guevara Subject: RE: Boys &Girls Club Insurance Thank you for the update! I will follow up with the B&G Club. -----Original Message----- From: Maria Guevara Sent: Monday, April 04, 2005 10:37 AM To: Karen Crocker Subject: Boys &Girls Club Insurance Hi Karen, This Friday I'll be adding them to the non-compliance list. I just received a notice that their workers comp insurance has been cancelled since 1/1/05. 1 will send you over a copy of the cancellation. Thanks for your help, Maria Guevara, Administrative Secretary City of San Juan Capistrano City Clerk Division (949) 443-6309 i Maria Guevara From: Maria Guevara Sent: Monday,April 04, 2005 10:37 AM To: Karen Crocker Subject: Boys & Girls Club Insurance Hi Karen, This Friday I'll be adding them to the non-compliance list. I just received a notice that their workers comp insurance has been cancelled since 1/1/05. 1 will send you over a copy of the cancellation. Thanks for your help, Maria Guevara, Administrative Secretary City of San Juan Capistrano City Clerk Division (949) 443-6309 i STATE COMPENSATION INSURANCE FUND IN REPLY REFER TO: MARCH 28 , 2005 CITY OF SAN JUAN CAPISTRANO ATTN CITY CLERK' S OFFICE 32400 PASEO ADELANTO SAN JUAN CAPISTRANO CA 92675 CERTIFICATE OF WORKERS' ----------------------- COMPENSATION INSURANCE ---------------------- CANCELLATION NOTICE ------------------- RE: CERTIFICATE DATED JANUARY 1, 2005 THE WORKERS' COMPENSATION INSURANCE POLICY FOR THE EMPLOYER NAMED BELOW HAS BEEN CANCELLED EFFECTIVE JANUARY 1, 2005 AT 12 :01 A.M. IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT THE EMPLOYER NAMED BELOW EMPLOYER: BOYS AND GIRLS CLUB OF CAPISTRANO VALLEY 1 VIA POSITIVA SAN JUAN CAPD, CA 92675 POLICY 1381364-05 CUSTOMER SERVICE REPRESENTATIVE CUSTOMER SERVICE CENTER ( 877 ) 405-4545 1275 Market Street •San Francisco, CA 94103—1410 Mailing Address: P.O. Box 420807 - San Francisco, CA 94142-0807 SCIF 19102 T _ DUI—[0—[U1J3 WGU UOQ lU 111 IIO111 V11 VLLL anuununVL l un uv, a_au vuv vuv.a . . .^.. `A'i �■N' 7�.AONLY • :.,1nMv1ri IFWA JRA �•j1:'.i�•In,, •• ~ v is 10/29/03 1'rnJucer THIS CERTIFICATE IS ISSUED ASA MATTER Or INFORMATION MANION/TSEI.1 INSURANCP.AY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.0. DOX 36186DEN.THIS CERTIFICATE DOES NOT AMEND.EXTEND OR LOS ANGELES,CA.901136R THE COVERAGE AFFORDED SYTHE POLICIES BELOW (2131387.8294•I:AX 1213)789. COMPANIES AFFORDING COVERAGES IJC'.ti 0655274 ompany Invin•n�—•-- A Philadelphia lnsurmce Companies — compwry BOYS AND 611US C'LUIl IWCAPISTRANO VAIJMY D One Via PnnNva CmnnalW SAN III IAN CAPISI RANO,CA.92675 C Onl(,anY 11 �r 'MIS IS TO CGR711'Y'fHAr 7416 PULICIhS OF INSURANCE LISfED RELDW HAVE.n6:EN ISSUED I"1TI NhINSURED NAM[U A110VC FOR TryE PULIL`Y F'L=k100 INDICATED.NO'I WI'fl ISTANDINO ANY RCOUIRL-MENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCIIMCNT WITH RESPECT TO WI ITCH THIS CER71f ICATF.MAY BE ISSUED OR MAY PEN IAIN,THE INSURANCE AFFORDED BY 1'HF POLICIES DESCRIBED HCRCIN IS SUBJECT TO ALL TMC TERMS. EXCi.UMONS AND CONDITIONS OF SUCH POLICICS. LIM11 S SHOWN MAY NAVE BEEN RCCUCED BY PAID CI AIMS. CU u^ POLICY L.TR _ TYPC OF INSURANCE NUMBER INCEPTION [XPIRATWN _ 1.1mi'm A x CornM 9FNrena LmOaUV P111"K036083 1111/03 1111/04 GENCRALAGGREGATF $3,000,000 naUPIENCE FORM PRODVCTS'COMP/OPAGG $1,000,000 PERSONAL B ADV INJURY $1,000,000 EACH OCCURRENCE $1,000,000 FIRE DAMAGE(AnY one fire) $50,000 (h XCLL'DING MI.MRI:nS AND 9TAN) MED EXP(Any One peFSon) $5,000 AU1'OMODILE LIABILITY A _&NY AUTO COMBINED SINGLE LIMIT $1,000,000 X AIL CVIALI PIIPK036083 11/1/03 1111/04 F•crEOULEO AIJ _ X 11R=Aurob I'h1PK036OS3 1111/03 1111104 $1,000,000 X NON CM1.0 AUTor. PI IPK036083 1111/03 11/1/04 $1,000,000 EXCESS 1.1%1103 IV _..^^ •^_ EACf I OCCURRENCE uMUIa IIAI .kM AGGRCGATE UI I II^I I IAN LIM11RI ILA 101fM ACCIDENT COVERAGE MED LIMIT rRIMARY SICKNESS CACFSS DCOUCTIBLE %FDUCTOLE „ OTHER DEECNW nON OF 0PFRATION51L=AT1ONt/ i1CLFSI9PEONL TEMu ^_ Cerlificale Holder is included as additional insured but only as respects the operations of[lie Nantcd Insured performed and use of properly(; One Via Positiva, S]C, CA Re: Boys and Girls Club/!teal Property Lease Agreement W Refer to Endorsement PI-NP-003(5/01)for wording. ER F16ATE !4_M Il"R cNn1.1,D ANY Or nm A110 nlsCrRI1103 M.N.M%BF•rANrm.cO DrrORE Ti IC City of San Juan Capistrano CXPI RATION DA I P.111ARGOP,TI IB ISSUING COM PANY WILL MAIL TO DAYS it's officers, agents and employees uT n1'fNrvo Rc¢ron�cBn nrlCnlEImLDRRNnnien TD THP LRPrlexmpe 32400 Paso Adelanto in ewe ur n0R-P3yment 0f PNMionl Wherein R 10 Jay notice will San Juan Capistrano, CA 92675 be kivCn). nUul(iRICED ftkSENTn11VC� G�� • • PI-NP-003 (5/01) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. GENERAL LIABILITY DELUXE ENDORSEMENT It is understood and agreed that the following extensions only apply in the event that no other specific coverage for the indicated loss exposures are provided under this policy, If such specific coverage applies, the terms, conditions and limits of that coverage are the sole and exclusive coverage applicable under this policy. Throughout this endorsement the words "you" and "your" refer to the Named Insured shown in the Declarations. The words "we" "us" and "our" refer to the Company providing this insurance. This endorsomont modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE The following Is a summary of the limits of Insurance and additional coverage provided by this endorsement. For complote details on specific coverages, consult the policy contract wording. A. Medical Payments - Limit increased to$15,000; B. Supplementary Payments- Bail bonds increased to S2,500/1-oss of earnings increased to S500each day; C. Tenant's Legal Liability - for Fire, Lightning, Explosion, Smoke and Leaks from Sprinklers - Limit increased to$300,000; D. Broadened Definition of Who is An Insured; E. Amended Duties In The Evont Of Occurrence, Claim Or Suit; F, Broadened definition of Advertising Injury- includes Televised Or Videotaped Publication; G. Amended definition of Bodily Injury to include Mental Anguish; H. Broadened definition of Personal Injury- includes Abuse of Process/discrimination; I. Amended Unintentional Failure To Disclose Hazards; J. Amended Liberalization Clause K. Added Employee Indemnification Defense Coverage - We will pay up to $25,000in defense costs for an "employeo"In a criminal proceeding (subject to established criteria); L. "Property Damage"- Removed exclusion for "Property damage"resulting from the use of reasonable force to protect persons or property; M. Added blanket Additional Insured- Funding Source; N. Added blanket Additional Insured- Managers or Lessors of Premises; O. Added General Aggregate Limit Per location; P. Non-owned Watercraft - coverage length is increased to 53 it.,- Page t.;Page 1 of 5 Includes copyright rnateflal of the Insurance sorvices office,Inc.used with its permission. PI-NP-003 (5/01) A. Medical Payments If Medical Payments Coverage (Coverage C.) Is not otherwise excluded from this Coverage Part: 1. The Medical Expense Limit is changed subject to all the terms of Limits Of Insurance (Section III) to the greater of: a. $15,000; or b. The Medical Expense Limit shown in the Declarations of this Coverage Part. 2. The requirement in the Insuring Agreement of Coverage C., that expenses must be incurred and reported to us within "one year" of the accident date is changed to "three years." 3. Exclusion a. of Coverage C. at your option, does not apply to your volunteer workers or any person or organization under your direct supervision and control. B. Supplementary Payments In the Supplementary Payments - Coverages A. and B. provision: 1. The limit for the cost of bail bonds is changed from $250 to $2,500; and 2. The limit for loss of earnings is changed from $250 a day to $500 a day. C. Fire, Lightning, Explosion, Smoke and Leaks from Sprinklers If damage, by fire to premises rented to you Is not otherwise excluded from this Coverage Part, the word "fire" is changed to "fire, lightning, explosion, smoke, or leakage from automatic fire protectide systems" where it appears In: 1. The Limits Of Insuranco section of the Declarations as the Fire Damage Limit. That limit: a. Is changed subject to all the terms of Limit Of Insurance (Section III) to the greater of: (1.) $300,000; or (2,) The amount shown in the declarations as the Fire Damage Limit. b. Subject to a. above is the most we will pay to all damage proximately caused by the same event, whether such damage results from fire, lightning, explosion, smoke, or leaks from automatic fire protective systems or any combination thereof. 2. The last paragraph of Coverage A_ (Section 1) after the Exclusions; 3. Paragraph 6, of Limits of Insurance (Section III); 4. Paragraph b.(1)(b) of the Other Insurance Condition (Section IV); and 5. Paragraph a. of the definition of "insured contract" D. Who is An Insured Who Is An Insured (Section II) Is changed as follows_ 1. If coverage for newly acquired or formed organizations is not otherwise excluded from this Coverage Part. paragraph 4.a is changed to read: a. Coverage under this provision is afforded until the end of the policy period. 2. Each of the following is also an insured: a. At the first Named Insured's option, your volunteer workers; and b. Your medical directors and administrators, but only while acting within the scope of and during the course of their duties as such. Such duties do not include the furnishing or failure to furnish professional services of any physician or psychiatrist in the treatment of a patient. c. At the first Named Insured's option, any person or organization under your direct supervision and control while providing for you private home respite or foster home care for the developmontally disabled. However, the insurance afforded by b. above is excess over any other insurance covering any person or organization under your direct control or supervision. d. If you are an organization other than a partnership or joint venture, your managers and supervisors are also insureds, but only with respect to their duties as your managers and supervisors. o. Any organization and subsidiary thereof which you control and actively manage on the effective date of this Coverage Part. However, the Insurance afforded by e. above, for any organization and subsidiary thereof not named in the Declarations as a Named Insured, does not apply to injury or damage with respect to which an insured under this Coverage Part Is also an insured under another policy, or would be an insured under such policy but for its termination or the exhaustion of its limits of insurance. Page 2-of 5 Includes copyright material of the Insurance Services Office,Inc.used with its permission. • PI-NP-003 (5/01) E. Duties in The Event Of Occurrence, Claim Or Suit 1. The requirement in condition 2.a. (Conditions, Section IV) that you must see to it that we are notified as soon as practicable of an "occurrence" or an offense, applies only when the "occurrence" or offense Is known to: (a) You, if you are an individual; (b) A partner, if you are a partnership: or (c) An executive officer or Insurance manager, if you are a corporation. 2. The requirement in condition 2.b. that you must see to it that we receive notice of a claim or "suit" as soon as practicable will not be considered breached unless the breach occurs after such claim or"suit" is known to: (a) You, if you are an Individual; (b) A partner, if you are a partnership; or (c) An executive officer or insurance manager, if you are a corporation. F. Advertising Injury - Televised Or Videotaped Publication 1. 'The definition of "Personal and advertising injury" items 14. (d),(e), (f) and (g) is changed to rear]: "Personal and Advertising Injury" means Injury arising out of one or more of the following offenses: d. Oral, written, televised or videotaped publication of material that slanders or libels a person or organization or disparages a person's or organization's goods, products or services; e. Oral, written, televised or videotaped publication of material that violates a person's right of privacy; f. Missappropriation of advertising Ideas or style of doing business; or g, Infringement of copyright, title or slogan. 2. Exclusions a. (2) and a. (3) of Coverage B., Personal And Advertising Injury Liability, are changed to read: a. (2) Arising out of oral, written, televised or videotaped publication of material, if done by or at the direction of the insured with knowledge of its falsity; a. (3) Arising out of oral, written, televised or videotaped publication of material whose first publication took place before the beginning of the policy period, G. Bodily Injury - Mental Anguish The definition of "bodily injury" is changed to read: "Bodily Injury": a. Means bodily injury, sickness or disease sustained by a person, and includes mental anguish resulting from any of these; and b. Except for mental anguish, includes death resulting from the foregoing (item a. above) at any time. H. Personal Injury - Abuse Of Process/Discrimination If Personal and Advertising Injury Liability Coverage (Coverage B.) Is not otherwise excluded from this Coverage Part: 1. The definition of "Personal and advertising injury" is changed by: a. Revising item b. of that definition to read: Malicious prosecution or abuse of process: b. Adding the following: "Personal Injury" also means discrimination based on race, color, religion, sex, age or national origin, except when: (1) Done intentionally by or at the direction of, or with the knowledge or consent of: (a) Any Insured; or (b) Any executive officer, director, stockholder, partner or member of the insured; or (2) Directly or Indirectly related to the employment, former or prospective employment, termination of employment, or application for employment of any person or persons by an Insured; or Page 3 of 5 Includes copyright motorial of the Insuranco Samicas office,Inc.used with it.^,pennission. PI-NP-003 (5/01) (3) Directly or Indirectly related to the sale, rental, lease or sub-lease or prospective sales, rental, lease or sub-lease of any room, dwelling or premises by or at the direction of any insured; or (4) Insurance for such discrimination Is prohibited by or held in violation of law, public policy, legislation, court decision or administrative ruling. 'The insurance afforded by Kl.b. above doers not apply to fines or penalties imposed because of discrimination. 1. Unintentional Failure To Disclose Hazards It Is agreed that, based on our reliance on your represontations as to existing hazards, if you should unintentionally fail to disclose all such hazards prior to the beginning of the policy period of this Coverage Bart, we shall not deny coverage under this Coverage Part because of such failura. J. Liberalization If we revise this endorsement to provide more coverage without additional premium charge, we will automatically provide the additional coverage to all endorsement holders as of the day the revision is effective in your state. K. Employee indemnification Defense Coverage Under SUPPLEMENTARYPAYMENTS- COVERAGESA AND B the following is added: 3. We will pay on your behalf defense costs incurred by an "employee" In a criminal proceeding. However, you must have a prior written agreement with such "employee" whereby you agree to indemnify the "employee" for such defense costs and the agreement includes a provision for repayment of defense costs In the event of an adverse judgement. The most we will pay for any "employee" who is alleged to be directly involved in a criminal proceeding is $25,000 regardless of the number of employees, claims or "suits" brought or persons or organizations making claims or bringing "suits." L. Extended "Property Damage" SECTION 1 • COVERAGES,COVERAGEA, 'L. Exclusionsa. is deleted and replaced by the following: a. Expected or Intended Injury "Bodily Injury" or "Property Damage" expected or intended from the standpoint of the insured. This exclusion does not apply to "bodily injury" or "property damage" resulting from the use of reasonable force to protect persons or property. M. Additional Insured - Funding Source Under SECTION II -WHO IS AN INSURED the following is added: 5. Any person or organization with respect to their liability arising out of: a. 'Their financial control of you; or b. Premises they own, maintain or control while you lease or occupy these premises. Trois insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization. N. Additlonsl Insured - Managers or Lessors of Premises Under SECTION 11 -WHO IS AN INSURED the following Is added: 5. Any person or organization with respect to their liability arising out of the ownership, maintenance or use of that part of the premises leased to you subject to the following additional exclusions: This insurance does not apply to: a. Any 'occurrence" which takes place after you cease to be a tenant in that premises. b. Structural alterations, new construction or demolition operations performed by or on behalf of that person or organization. Page 4 of 5 tndudes copyright malarial of Utc Insurance Services^Office,Inc,us5d with its permission. PI-NP-003 (5101) O. General Aggregate Limit Per location SECTION III - Llmitsof Insurance,paragraph 2, is amended to the following: The General Aggregate Limit is the most we will pay for the sum of: a. Medical expenses under Coverage C; b. Damages under Coverage A, except damages because of "bodily injury" or"property danage" included in the "products-completed operations hazard"; and c. Damages under Coverage B. A separate Location General Aggregate Limit applies to each "location", and that limit Is equal to the amount of the General Aggregate Limit shown in the Declarations. SECTION V - DEFINITIONS, Is amended by adding the following: "Location" means promises involving the same or connecting lots, or premises whose connection Is interrupted only by a street, roadway, Waterway or tight-of-way of a railroad. P. Non-owned Watercraft SECTION I - COVERAGES,2.Exclusions,paragraph g, (2) is amended to read as follows: (2) A watercraft you do not own that Is: (a) less than 58 feet long; and (b) Not being used to carry persons or property for a charge; This provisicn applies to any person, who with your consent, either uses or is responsible for the use of a watercraft. This insurance is excess over any other valid and collectible insurance available to the insured whether primary, excess or contingenl. Page 5 of 5 inciudos copyrignt moter.'al of ilio Insurance services Cffico,Inc.used with its permission. • OTHOLDERCOPY SG STATE P.O. BOX 807, SAN FRANCISCO,CA 94142-0807 COMPENSATION - INSURANCE ' FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 01-01-2002 GROUP: POLICY NUMBER: 1381384-2003 CERTIFICATE ID: 3 CERTIFICATE-EXPIRES: 01-01-2004 01-01-2003/01-01-2004 CITY OF SAN JUAN CAPISTRANO SG JOB: AFTER SCHOOL RECREATION ATTN CITY CLERK'S OFFICE PROGRAMS REAL PROPERTY 32400 PASEO AOELANTO LEASE,,A MERtS i SAN JUAN CAPISTRANO CA 92675 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 10 days' advance written notice to the employer. We will also give you 10 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 conditionof 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.fs AUTHORIZED REPRESENTATIVE PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: 81,000,000.00 PER OCCURRENCE. N a z c rn �r �� rn a v o ^z EMPLOYER BOYS AND GIRLS CLUB OF CAPISTRANO VALLEY (A NON-PROFIT PUBLIC BENEFIT CORP) 1 VIA POSITIVA SAN JUAN CAPO CA 92675 THIS DOCUMENT a BACKGROUND PRINTED: '12-13-2002 P0408 r� Producer THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION MANION/BELL INSURANCE ASSOCIATES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O. BOX 36186 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR LOS ANGELES,CA. 90036 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW (213)387-8294`FAX(213)389-5833 COMPANIES AFFORDING COVERAGES LIC.1110655274 Company InSured A Philadelphia Insurance Companies Company BOYS AND GIRLS CLUB OF CAPISTRANO VALLEY B One Via Positiya Company SAN JUAN CAPISTRANO,CA.92675 c ' l t tr Company D 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 REOUIREMENT,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 POLICY LTR TYPE OF INSURANCE NUMBER INCEPTION EWIMTION LIMITS —ACaE.ERAL.IA-LITY PHPK036083 11/1/02 11/1/03 GENERAL AGGREGATE $3,000,000 occuRRENLE FORM PRODUCTS'COMP/OP AGG $1,000,000 OTHER PERSONAL&ADV INJURY $1,000,000 EACH OCCURRENCE $1,000,000 FIRE DAMAGE(Any one fire) $50,000 (EXCLUDING MEMBERS AND STAFF) MED EXPIAny one person) $5,000 AUTOMOBILE LIABILITY A ANY AUTO COMBINED SINGLE LIMIT $1,000,000 X ALL OWNED AUTOS PFIPK036083 11/1/02 11/1/03 SCHEDULED AUTOS M HIRED AUTOS PHPK036083 11/1/02 11/1/03 $1,000,000 X NONOWNEDAUTOS PHPK036083 11/1/02 II/1/03 $1,000,000 EXCESS LIABILITY EACH OCCURRENCE UMBRELLA FORM AGGREGATE N OTHER THAN UMBREELA FORM O ACCIDENT COVERAGE MED LIMIT L PRIMARY SICKNESS > EXCESS DEDUCTIBLE 1 DEDUCTIBLE OTHER r DESCRIPTION OF OPERATIONSXOCATIONSNEHMLES/SPECIAL ITEMS G O Certificate Holder is included as additional insured but only as respects the operations of the Named Insured performed. Re: Boys and Girls Club/Real Property Lease Agreement Endorsement has been ordered and will follow as soon as received SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELED BEFORE THE City of San Juan Capistrano EXPIRATION DATE THEREOF,ME ISSUING COMPANY WILL MAIL 30 DAYS it's officers, agents and employees WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFTORI 32400 Paso A Delanto in care ofnon-payment ofprenium wherein a 10 day notice will San Juan Capistrano, CA 92675 be given). AUTHORIZED REPRESENTATIVE C.9- .,.9I,Gc:�c,stc DEC-09-2002 MON 03 14 PM MANION BELL INSURANCE FAX NO. 213 389 5833 P. 03 • PI-NP-003 (5(01) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. GENERAL LIABILITY DELUXE ENDORSEMENT It is understood and agreed that the following extensions only apply in the event that no other specific coverage for the Indicated loss exposures are provided under this policy. If such specific coverage applies, the terms,conditions and limits of that coverage are the sole and exclusive coverage applicable under this policy. Throughout this endorsement the words "you" and "your" refer to the Named Insured shown in the Declarations. The words "we" "us" and "our" refer to the Company providing this Insurance. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE The following is a summary of the Limits of Insurance and additional coverage provided by this endorsement. For complete details on specific coverages, consult the policy contract wording. A. Medical Payments - Limit increased to$15,000; B. Supplementary Payments- Sail bonds increased to $2,500/Loss of earnings increased to$500 each day; C. Tenant's Legal Liability-for Fire, Lightning, Explosion, Smoke and Leaks from Sprinklers- Limit increased to$300,000; D. Broadened Definition of Who is An insured; E, Amended Duties In The Event Of Occurrence, Claim Or Suit; F. Broadened definition of Advertising Injury-includes Televised Or Videotaped Publication,- G. ublication;G. Amended definition of Bodily Injury to include Mental Anguish; H. Broadened definition of Personal injury- includes Abuse of Process/discrimination; 1. Amended Unintentional Failure To Disclose Hazards; J. Amended Liberalization Clause K. Added Employee Indemnification Defense Coverage - We will pay up to 525,000 in defense costs for an "employee"in a criminal proceeding(subject to establishedcriferia); L. "Property Damage"- Removed exclusion for "Property damage"resuping from the use of reasonable force to protect persons or property; M. Added blanket Additional Insured-Funding Source; N. Added blanket Additional Insured-Managers or Lessors of Premises; O. Added General Aggregate Limit Per location; P. Non-owned Watercraft-coverage length is increased to 58 it.,- Page t.;Page 1 of 5 Inaludcs copyright material of the Insuranca Gamicou coca,Inc.uecd whh its pwmissbn. DEC-09-2002 MON 0315 PM MANION BELL INSURANCE FAX NO, 213 389 5833 P. U4 • PI-NP-003 (5/01) A. Medical Payments If Medical Payments Coverage (Coverage C,) is not otherwise excluded from this Coverage Part: 1. The Medical Expanse Limit is changed subject to all the terms of Limits Of Insurance(Section III) to the greater of: a. $15,000; or b, The Medical Expense Limit shown in the Declarations of this Coverage Part. 2. The requirement in the Insuring Agreement of Coverage C.,that expenses must be incurred and reported to us within "one year" of the accident date is Changed to"three years.' 3. Exclusion a, of Coverage C. at your option, does not apply to your volunteer workers or any parson or organization under your direct supervision and control. H. Supplementary Payments In the Supplementary Payments - Covorages A. and B. provision: 1. The limit for the cost of bail bonds is changed from $250 to $2,500; and 2. The limit for loss of earnings is changed from $250 a day to$500 a day. C. Fire, Lightning, Explosion,Smoke and Leaks from Sprinklers If damage by fire to premises rented to you is not otherwise excluded from this Coverage Part, the word "tire" is changed to "fire, lightning, qxplosion, smoke, or leakage from automatic fire protective systems"where it appears in: 1. The Limits Of Insurance section of the Declarations as the Fire Damage Limit. That limit: a. Is changed subject to all the terms of Limit Of Insurance (Section III) to the greater of: (1.) $300,000; or (2,) The amount shown in the declarations as the Fire Damage Limit. b. Subject to a, above is the most we will pay to all damage proximately caused by the same event, whether such damage results from fire, lightning, explosion, smoke, or leaks from automatic fire protective systems or any combination thereof. 2. The last paragraph of Coverage A. (Section 1) after the Exclusions; 3. Paragraph 6. of Limits of Insurance (Section ill); 4. Paragraph b.(1)(b) of the Other Insurance Condition (Section IV); and 5. Paragraph a. of the definition of "insured contract" D. Who Is An Insured Who is An Insured (Section II) is changed as follows: 1. If coverage for newly acquired or formed organizations is not otherwise excluded from this Coverage Part. paragraph 4.a is changed to read: a. Coverage under this provision is afforded until the and of the policy period. 2. Each of the following is also an insured: a. At the first Named Insured's option, your volunteer workers; and b, Your medical directors and administrators, but only while acting within the scope of and during the course of their duties as such. Such duties do not include the furnishing or failure to furnish professional services of any physician or psychiatrist in the treatment of a patient. c. At the first Named Insured's option, any person or organization under your direct supervision and control while providing for you private home respite or foster home care for the developmentally disabled. However, the insurance afforded by b. above is excess over any other insurance covering any person or organization under your direct control or supervision. d. If you are an organization other than a partnership or joint venture, your managers and supervisors are also insureds, but only with respect to their duties as your managers and supervisors. e. Any organization and subsidiary thereof which you control and actively manage on the effective date of this Coverage Part. However, the insurance afforded by e, above,for any organization and subsidiary thereof not named In the Declarations as a Named Insured, does not apply to injury or damage with respect to which an insured under this Coverage Part is also an insured under another policy, or would be an insured under such policy but for its termination or the exhaustion of its limits of insurance. Page 2 of 5 Includes copyright material of the Insurance Services Office.Inc.used with trs parmissim. DEO-09-2002 MON 03; 15 PM MANION BELL INSURANCE FAX N0. 213 3 5833 P. 05 • PI-NP-003 (5/01) E. Duties In The Event Of Occurrence, Claim Or suit 1. The requirement in condition 2.a. (Conditions, Section IV) that you must see to it that we are notified as soon as practicable of an "occurrence' or an offense, applies only when the "occurrence"or offense Is known to: (a) You, if you are an individual; (b) A partner, if you are a partnership: or (c) An executive officer or insurance manager, if you are a corporation. 2. The requirement in condition 2.b.that you must see to it that we receive notice of a claim or "suit" as soon as practicable will not be considered breached unless the breach occurs after such claim or "suit" is known to; (a) You, if you are an Individual; (b) A partner, if you are a partnership; or (c) An executive officer or insurance manager, if you are a corporation. F. Advertising Injury •Televised Or Videotaped Publication 1. The definition of "Personal and advertising injury" items 14. (d),(e), (f) and (g) is changed to read: "Personal and Advertising injury" means injury arising out of one or more of the following offenses: d. Oral, written, televised or videotaped publication of material that slanders or libels a person or organization or disparages a person's or organization's goods, products or services; e. Oral, written, televised or videotaped publication of material that violates a person's right of privacy; I, Missappropriation of advertising Ideas or style of doing business; or g. Infringement of copyright, title or slogan. 2. Exclusions a. (2) and a. (3) of Coverage B., Personal And Advertising Injury Liability.are changed to read: a- (2) Arising out of oral, written, televised or videotaped publication of material, it done by or at the direction of the Insured with knowledge of Its falsity; a. (3)Arising out of oral, written, televised or videotaped publication of material whose first publication took place before the beginning of the policy period. G, Bodily Injury-Mental Anguish The definition of"bodily Injury" is changed to read: "Bodily Injury": a. Means bodily injury, sickness or disease sustained by a person, and includes mental anguish resulting tram any of these; and b, Except for mental anguish, includes death resulting from the foregoing (item U. above)at any time. H. Personal Injury-Abuse Of ProcesslDiscrimination 11 Personal and Advertising Injury Liability Coverage (Coverage B.) is not otherwise excluded from this Coverage Part: 1. The definition of "Personal and advertising injury" is changed by: a. Revising item b. of that definition to read: Malicious prosecution or abuse of process: K Adding the following: "Personal injury" also means discrimination based on race, color, religion, sex, ago or national origin, except when. (1) Done intentionally by or at the direction of, or with the knowledge or consent of: (a) Any insured; or (b) Any executive officer, director, stockholder, partner or member of the insured; or (2) Directly or indirectly related to the employment, former or prospective employment, termination of employment, or application for employment of any person or persons by an Insured; or Page 3 of 5 Includes copyright material of the inswama services office,inc.usee with Its permission. DEC-09-2002 MON 03:15 PM MANION BELL INSURANCE FAX NO. 213 389 5833 P. 06 PI-NP-003 (5/01) (3) Directly or indirectly related to the sale, rental, lease or sub-lease or prospective sales, rental, lease or sub-lease of any room, dwelling or premises by or at the direction of any insured; or (4) Insurance for such discrimination is prohibited by or held In violation of law, public policy, legislation, court decision or administrative ruling, The insurance afforded by H.1.b. above dues not apply to fines or penalties imposed because of discrimination. 1, Unintentional Failure To Disclose Hazards It is agreed that, based on our reliance on your representations as to existing hazards, if you should unintentionally fail to disclose all such hazards prior to the beginning of the policy period of this Coverage Part, we shall not deny coverage under this Coverage Part because of such failure. J. Liberalization If we revise this endorsement to provide more coverage without additional premium charge, we will automatically provide the additional coveread to all endorsement holders as of the day the revision is effective in your state, K. Employee Indemnification Defense Coveiage Under SUP PLEMENTARYPAYMENTS-COVERAGESA AND S the following is added: 3. We will pay on your behalf defense costs incurred by an "employee" in a criminal proceeding. Howeyer, you must have a prior written agreement with such "employes"whereby you agree to indemnify the "employee"for such defense costs and the agreement includes a provision for repayment of defense costs in the event of an adverse judgement. The most we will pay for any "employes"who is alleged to be directly Involved in a criminal proceeding is $25,000 regardless of the number of employees, claims or"suits"brought or persons or organizations making claims or bringing "suits." L. Extended "Property Damage" SECTION 1 -COVE RAGES,COVERAGE A,2. Excluslonsa, is deleted and replaced by the following: a. Expected or Intended Injury "Bodily Injury" or 'Property Damage" expected or intended from the standpoint of the insured. This exclusion does not apply to "bodily injury" or "property damage" resulting from the use of reasonable force to protect persons or property. M. Additional Insured - Funding Source Under SECTION 11 -WHO IS AN INSURED the following Is added: 5. Any person or organization with respect to their liability arising out of: a. Their financial control of you; or b. Premises they own, maintain or control while you lease or occupy these premises. This insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization. N. Additions) Insured� Managers or Lessors of Premises Under SECTION 11 -WHO IS AN IN the following is added: 6. Any person or organization with respect to their liability arising out of the ownership, maintenance or use of that part of the premises leased to you subject to the following additional exclusions: This insurance does not apply to: a. Any "occurrence" which takes place after you cease to be a tenant in that premises. b. Structural alterations, new construction or demolition operations performed by or on behalf of that person or organization. Page 4 of 5 Includes copyright rnaterlol of the Insurance servlcos Offico,Inc.used with Wn nnrmineinn DEC-09-2002 MON 03116 PM MANION BELL INSURANCE FAX NO. 213 389 5833 P. 07 PI-NP-003 (5/01) O, General Aggregate Limit Per location SECTION III - Limits of Insurance,paragraph 2. is amended to the following: The General Aggregate Limit is the most we will pay for the sum at: a. Medical expenses under Coverage C; b. Damages under Coverage A, except damages because of "bodily injury" or "property damage" included in the "products-completed operations hazard"; and c. Damages under Coverage S. A separate Location General Aggregate Limit applies to each "location", and that limit is equal to the amount of the General Aggregate Limit shown In the Declarations. SECTION V-DEFINITIONS, is amended by adding the following: "Location" means premises involving the same or connecting lots, or premises whose connection is interrupted only by a street, roadway, waterway or right-of-way of a railroad. P. Non-owned Watercraft SECTION I- COVERAGES,2.Exclusions,paragraphg,(2) is amended to read as follows: (2) A watercraft you do not own that Is: (a) Less than 58 feet long; and (b) Not being used to carry persons or property for a charge; This provision applies to any person, who with your consent, either uses or is responsible for the use of a watercraft This Insurance is excess over any other valid and collectible insurance available to the insured whether primary, excess or contingent. Page 5 or 5 Includes copyright material or the Insurance services ofrce,Inc,used with its permbslon. Dawn Schanderl To: Karen Crocker Cc: Al King Subject: Boys&Girls Club Received certificate but still need the endorsement. Thanks t OCT-31-2002 17.24 MANION BELL 32400 PASEe gOHu.NTo ��'py nmmTu+ SAN JUAN CAPISTRANO. CA 9267$ p1U11310 �SEt MEMREN QFTNE qtt COUNCIL t9a9) 493-1171 V76 R NE L DA�HGATE (949) 493-1053 (FAX) JOHN CAM➢BE71 ♦ N 6.GEur WWU'.SOAJtlnrrCOrl(Jl(On O.OTjt DAM HART ♦ OAVID M.6WEROUN CM MANAGER GEORGESGR9OReUGH October 28, 2002 { Boys & Girls Club of Capistrano Valley San Juan Capistrano, CA 92675 RE: Compliance with Insurance Requirements - After School Recreation Program/Property Lease The following insurance documents are due to expire: V' General Liability Certificate 11/1/2002 V General Liability Endorsement naming the City of San Juan Capistrano as r additional insured. V Automobile Liability Certificate 11/1/2002 Please submit updated documentation to the City of San Juan Capistrano, attention City Clerk's office, 32400 Paseo Adelanto, San Juan Capistrano, CA 92675 by the above expiration dates. If you have any questions, please contact me at (949) 443-6310. Sincerely, XWRM21117a'�� Dawn M. Schandert Deputy City Clerk cc: A! King, Jr., Community Services Director Karen Crocker, Community Services Manage r s,! .Cnn -17,, �'iTnicl' D,- .L_ i�__. . - 1 T .� OCT-31-2002 17:25 MANION BELL P.02i02 10/31/02 Producer THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION MAMION10ELL INSURANCE ASSOCIATES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O. )]OX 36186 HOLDER.THIS CERTIFICATE DOES NOT AMEND.EXTEND OR LAS ANGELES,CA-901136 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW (213)387-82940,FAX(213)389-5833 COMPANIES AFFORDING COVERAQES LTC.N 0655274 Ce P_, a A Phlbdelphla InRmnce Company CO.,., BOYS AND GIRLS CLUB OF CAPISTRANO VALLEY e One Vu Pmldva Company SAN JUAN CAPISTRANO,CA 92675 C ompanY D THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW NAVE BEEN ISSUED TO THE INSURED NAMED ADOW FOR THE POLICY PEPo00 %WtCATEO,NUT WITHSTANgNO ANY F MOMEMENT,TEAM OR CONDITION OF ANY COWHACT OR OTHER DOCUMENT WITH RESPECT TO V X:.THIS CERTIOCATE MAY BF IGSUEO OR MAY PERTAIN.TME INSURANCE AFFORDED BY THE MUCIES DESCMBED HEREIN 15 SUBJECT TO ALL THE TERMS, EXCW60NS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED By PAID CLAIMS. CO MUCY LTR ME OF IN6UMNFS NUMBER Imck"Oa u MN OMITS A JEON. PHYLOI-2DO2344 11/1/02 11/1/03 GENERAL AGGREGATE $3.000,000.00 9CN.NLN4E Po PRODUCTS-COMP/OP AGO $1,000,000,00 OTAIA PERSONAL&ADV INJURY $1.000.000.00 EACH OCCURRENCE 41.000.000.00 FIRE DAMAGEIAW one fire) $50,000.00 (EXCLUDING MEMBERS AND STAFF) MED EXPIA.Y one Parson) $5,00(.00 AUTUMMIL LIABILITY A ANY..10 COMBINED SINGLE LIMIT 11,0001000.00 X .I.LO .W AUTOS PHYLOI-2002344 11/1/02 11/1/03 SdEgAio M/ios N MNm AUTO PLiyL01-2002344 1111/02 11/1/03 a NOfI.0 N113 AUTOS PHYL01-2007344 11/1/02 11/1/03 EXCESS LIABILITY EACH OCCUwENCE uNPELLA NMT AGGREGATE OTNOTBAN BMaaELU1 W aH AGOOENT COVEMOE MED DART PNMARV SICKNESS EAFE6F DEDUCTIBLE oENJCTVEE OTHER EHCNPnON m DFOAvmrAATgATalwnlaciaamPawL ITFrtN Certificate Holder is included as additional insured but only as respects the operations of the Named Insured performed. _Re: Boys and Girls Club/Real Property Lease Agreement Endorsement has been ordered and will follow as soon as received SHOULD ANY of TRE ABOVE DF3GNB®POIJCHO W cAmmev BRPDXR THE City of San Juan Capistrano EXPiMTiUN MTETNBABOF,TxP.1]SUmOIX>sIPANY WIIYMAIL>D DATE it's officers, agents and employees warrTEN NoncemTHE CBRTeIGATE NOIJmRNAMLV To rxa LeEr(.,inll 32400 Paso A Delant0 in cmc ol'Noo-payment otprcmiom vhw in a 10 day native will San Juan Capistrano, CA 92675 be givm). AUTHORIZED WP ENTATIVE TOTAL P.02 32400 PASE7 ADELANTO BRRNNB SAN JUAN CAPISTRANO, CA 92675 I MEMBERS OF THE CItt COUNCIL (949) 493-1171 u1776 1961 1776 OE N BATHGATE CD (949) 493-1053 (FAX) & JOHNS. CAMRBEu JOHN S.GEUT M"D )vlvlv.sanjuancapislrgno.Olg HART OANO M.SWERWN CITYMANAGER GEORGESCARBOROUGH October 28, 2002 Boys & Girls Club of Capistrano Valley 1 Via Positiva San Juan Capistrano, CA 92675 RE: Compliance with Insurance Reguirements - After School Recreation Program/Property Lease The following insurance documents are due to expire: V General Liability Certificate 11/1/2002 General Liability Endorsement naming the City of San Juan Capistrano as r additional insured. V Automobile Liability Certificate 11/1/2002 Please submit updated documentation to the City of San Juan Capistrano, attention City Clerk's office, 32400 Paseo Adelanto, San Juan Capistrano, CA 92675 by the above expiration dates. If you have any questions, please contact me at (949) 443-6310. /Sincerely, "� Dawn M. Schanderl Deputy City Clerk cc: Al King, Jr., Community Services Director Karen Crocker, Community Services Manager Daae� n San Juan Capistrano: Preserving the Past to Enhance the Future 08.05-2002 COMMERCIAL GUARANTY Page 3 Loan No BOYS • (Continued) • EACH UNDERSIGNED GUARANTOR ACKNOWLEDGES HAVING READ ALL THE PROVISIONS OF THIS GUARANTY AND AGREES TO ITS TERMS. IN ADDITION, EACH GUARANTOR UNDERSTANDS THAT THIS GUARANTY IS EFFECTIVE UPON GUARANTOR'S EXECUTION AND DELIVERY OF THIS GUARANTY TO LENDER AND THAT THE GUARANTY WILL CONTINUE UNTIL TERMINATED IN THE MANNER SET FORTH IN THE SECTION TITLED "DURATION OF GUARANTY." NO FORMAL ACCEPTANCE BY LENDER IS NECESSARY TO MAKE THIS GUARANTY EFFECTIVE. THIS GUARANTY IS DATED AUGUST 5,2002. GUARANT CITY OF J N A ISTRANO BY eor Man ger LASER PRO.Reg.JVS.Pat.&T.M.. .,Ver.3.29a(C)Concentm 1999 Al tlghts reserved.IMO-E20A E3.29 F3.29 BOYS.W CI.OVL] 08.05-2002 • CommtRCIAL GUARANTY • Page 2 Loan No BOYS (Continued) Guarantor also waives any and all rights or defenses arising by reason of (a) any "one action" or "anti-deficiency" law or any other law which may prevent Lender from bringing any action, including a claim for deficiency, against Guarantor, before or after Lender's commencement or completion of any foreclosure action,either judicially or by exercise of a power of sale; (b)any election of remedies by Lender which destroys or otherwise adversely affects Guarantor's subrogation rights or Guarantor's rights to proceed against Borrower for reimbursement, including without limitation, any loss of rights Guarantor may suffer by reason of any law limiting,qualifying,or discharging the Indebtedness; (c)any disability or other defense of Borrower,of any other guarantor,or of any other person,or by reason of the cessation of Borrower's liability from any cause whatsoever,other than payment in full in legal tender,of the Indebtedness; (d)any right to claim discharge of the Indebtedness on the basis of unjustified impairment of any collateral for the Indebtedness; (e) any statute of limitations, if at any time any action or suit brought by Lender against Guarantor is commenced there is outstanding Indebtedness of Borrower to Lender which is not barred by any applicable statute of limitations; or (1) any defenses given to guarantors at law or in equity other than actual payment and performance of the Indebtedness. If payment is made by Borrower, whether voluntarily or otherwise, or by Guarantor or by any third party, on the Indebtedness and thereafter Lender is forced to remit the amount of that payment (a)to Borrower's trustee in bankruptcy or to any similar person under any federal or state bankruptcy law or law for the relief of debtors, (b)by reason of any judgment,decree or order of any court or administrative body having jurisdiction over Lender or any of Lender's property,or(c) by reason of any settlement or compromise of any claim made by Lender with any claimant(including without limitation Borrower or Guarantor),the Indebtedness shall be considered unpaid for the purpose of enforcement of this Guaranty and this Guaranty shall continue to be effective or shall be reinstated,as the case may be,notwithstanding any cancellation of this Guaranty or of any note or other instrument or agreement evidencing the Indebtedness and Guarantor shall remain liable for the amount repaid or recovered to the same extent as if that amount never had been originally received by Lender,and Guarantor shall be bound by any judgment,decree,order,settlement or compromise relating to the Indebtedness or to this Guaranty. Guarantor further waives and agrees not to assert or claim at any time any deductions to the amount guaranteed under this Guaranty for any claim of setoff, counterclaim, counter demand, recoupment or similar right, whether such claim, demand or right may be asserted by the Borrower, the Guarantor,or both. GUARANTOR'S UNDERSTANDING WITH RESPECT TO WAIVERS. Guarantor warrants and agrees that each of the waivers set forth above is made with Guarantor's full knowledge of its significance and consequences and that,under the circumstances,the waivers are reasonable and not contrary to public policy or law. If any such waiver is determined to be contrary to any applicable law or public policy, such waiver shall be effective only to the extent permitted by law or public policy. LENDER'S RIGHT OF SETOFF. In addition to all liens upon and rights of setoff against the moneys,securities or other property of Guarantor given to Lender by law, Lender shall have, with respect to Guarantor's obligations to Lender under this Guaranty and to the extent permitted by law, a contractual security interest in and a right of setoff against, and Guarantor hereby assigns, conveys, delivers, pledges, and transfers to Lender all of Guarantor's right,title and interest in and to,all deposits, moneys, securities and other property of Guarantor now or hereafter in the possession of or on deposit with Lender, whether held in a general or special account or deposit, whether held jointly with someone else, or whether held for safekeeping or otherwise, excluding however all IRA, Keogh, and trust accounts. Every such security interest and right of setoff may be exercised without demand upon or notice to Guarantor. No security interest or right of setoff shall be deemed to have been waived by any act or conduct on the part of Lender or by any neglect to exercise such right of setoff or to enforce such security interest or by any delay in so doing. Every right of setoff and security interest shall continue in full force and effect until such right of setoff or security interest is specifically waived or released by an instrument in writing executed by Lender. SUBORDINATION OF BORROWER'S DEBTS TO GUARANTOR. Guarantor agrees that the Indebtedness of Borrower to Lender, whether now existing or hereafter created, shall be prior to any claim that Guarantor may now have or hereafter acquire against Borrower,whether or not Borrower becomes insolvent. Guarantor hereby expressly subordinates any claim Guarantor may have against Borrower, upon any account whatsoever,to any claim that Lender may now or hereafter have against Borrower. In the event of insolvency and consequent liquidation of the assets of Borrower, through bankruptcy, by an assignment for the benefit of creditors, by voluntary liquidation, or otherwise, the assets of Borrower applicable to the payment of the claims of both Lender and Guarantor shall be paid to Lender and shall be first applied by Lender to the Indebtedness of Borrower to Lender. Guarantor does hereby assign to Lender all claims which it may have or acquire against Borrower or against any assignee or trustee in bankruptcy of Borrower; provided however, that such assignment shall be effective only for the purpose of assuring to Lender full payment in legal tender of the Indebtedness. If Lender so requests,any notes or credit agreements now or hereafter evidencing any debts or obligations of Borrower to Guarantor shall be marked with a legend that the same are subject to this Guaranty and shall be delivered to Lender. Guarantor agrees,and Lender hereby is authorized, in the name of Guarantor,from time to time to execute and file financing statements and continuation statements and to execute such other documents and to take such other actions as Lender deems necessary or appropriate to perfect, preserve and enforce its rights under this Guaranty. MISCELLANEOUS PROVISIONS. The following miscellaneous provisions are a part of this Guaranty: Amendments. This Guaranty,together with any Related Documents,constitutes the entire understanding and agreement of the parties as to the matters set forth in this Guaranty. No alteration of or amendment to this Guaranty shall be effective unless given in writing and signed by the party or parties sought to be charged or bound by the alteration or amendment. Applicable Law. This Guaranty has been delivered to Lender and accepted by Lender in the State of Missouri. If there is a lawsuit, Guarantor agrees upon Lender's request to submit to the jurisdiction of the courts of JACKSON County, State of Missouri. This Guaranty shall be governed by and construed in accordance with the laws of the State of Missouri. 0DOMMEACIALIGUARANTY t BB ............ .......... .... ..................... .. ........ References in the shaded area are for Lender's use only and do not limit the applicability of this document to any particular loan or Borrower: BOYS&GIRLS CLUB OF CAPISTRANO VALLEY Lender: AMERICAN STERLING BANK One Via Positive M S.STERLING SAN JUAN CAPISTRANO,CA 92676 PO BOX 8500 SUGAR CREEK,MO 64054 Guarantor: CITY OF SAN JUAN CAPISTRANO 32400 Paseo Adelanto Son Juan Capistrano,CA 92675 AMOUNT OF GUARANTY. This Is a guaranty of payment of the Note,Including without limitation the prind Fount of Seven Hundred Fifty Thousand&001100 Dollars ($750,000.00). GUARANTY. For good and valuable consideration,CITY OF SAN JUAN CAPISTRANO("Iunconditionally guarantees and promises to pay to AMERICAN STERLING BANK("Lender")or Its order,on demand, In legal tender of the United States of America,the Indebtedness (as that term Is defined below) of BOYS & GIRLS CLUB OF CAPISTRANO VALLEY("Borrower") to Lender on the terms and conditions set forth In this Guaranty. DEFINITIONS. The following words shall have the following meanings when used In this Guaranty: Borrower. The word"Borrower"means BOYS&GIRLS CLUB OF CAPISTRANO VALLEY. Guarantor. The word"Guarantor'means CITY OF SAN JUAN CAPISTRANO. Guaranty. The word"Guaranty"means this Guaranty made by Guarantor for the benefit of Lender dated August 5,2002. Indebtedness. The word 'Indebtedness' means the Note, including (a) all principal, (b) all interest, (c)all late charges, (d) all loan fees and loan charges, and (a) all collection costs and expenses relating to the Note or to any collateral for the Note. Collection costs and expenses include without limitation all of Lender's attorneys'fees and Lender's legal expenses, legal expenses for bankruptcy proceedings(including efforts to modify or vacate any automatic stay or injunction),appeals,and any anticipated post-judgment collection services. Lender. The word"Lender'means AMERICAN STERLING BANK,its successors and assigns. Note. The word "Note' means the promissory note or credit agreement dated . In the original principal amount of ) from Borrower to Lender, together with all renewals of, extensions of, modifications of, refinancings of, consolidations of, and substitutions for the promissory note or agreement. Related Documents. The words "Related Documents" mean and include without limitation all promissory notes, credit agreements, loan agreements, environmental agreements, guaranties, security agreements, mortgages, deeds of trust, and all other instruments, agreements and documents,whether now or hereafter existing,executed in connection with the Indebtedness. MAXIMUM LIABILITY. The maximum liability of Guarantor under this Guaranty shall not exceed at any one time the amount of the Indebtedness described above, plus all costs and expenses of (a)enforcement of this Guaranty and (b)collection and sale of any collateral securing this Guaranty. The above limitation on liability is not a restriction on the amount of the Indebtedness of Borrower to Lender either In the aggregate or at any one time. If Lender presently holds one or more guaranties,or hereafter receives additional guaranties from Guarantor,the rights of Lender under all guaranties shall be cumulative. This Guaranty shall not (unless specifically provided below to the contrary) affect or invalidate any such other guaranties. The liability of Guarantor will be the aggregate liability of Guarantor under the terms of this Guaranty and any such other unterminated guaranties. NATURE OF GUARANTY. Guarantor intends to guarantee at all times the performance and prompt payment when due,whether at maturity or earlier by reason of acceleration or otherwise,of all Indebtedness within the limits set forth In the preceding section of this Guaranty. Any married person who signs this Guaranty as the Guarantor hereby expressly agrees that recourse may be had against both his or her separate property and community property. DURATION OF GUARANTY. This Guaranty will take effect when received by Lender without the necessity of any acceptance by Lender,or any notice to Guarantor or to Borrower, and will continue In full force until all Indebtedness shall have been fully and finally paid and satisfied and all other obligations of Guarantor under this Guaranty shall have been performed in full. Release of any other guarantor or termination of any other guaranty of the Indebtedness shall not affect the liability of Guarantor under this Guaranty. A revocation received by Lender from any one or more Guarantors shall not affect the liability of any remaining Guarantors under this Guaranty. ....""°.°"..""„e A§I�U^m7AVJnM 7n i cuni;zo n,..,.ntnr ..dhnr!7wq I-Ander- without notice or demand and without lessening Guarantor's CORPOSTE RESOLUTION TO GUANTEE M. y ....... ....... ............... ................. ......... .......... References in the shaded area are for Lenders use only and do not limit the applicability of this document to any particular loan or item, Borrower: BOYS&GIRLS CLUB OF CAPISTRANO VALLEY Lender: AMERICAN STERLING BANK One Via Positive 535 S.STERLING SAN JUAN CAPISTRANO,CA 92675 PO BOX$500 SUGAR CREEK,MO 64054 Guarantor: CITY OF SAN JUAN CAPISTRANO 32400 Paseo Adelanto San Juan Capistrano,CA 92675 1, the undersigned Secretary or Assistant Secretary of CITY OF SAN JUAN CAPISTRANO (the "Corporation"), HEREBY CERTIFY that the Corporation is organized and existing under and by virtue of the laws of the State of California with its principal office at 32400 Paseo Adelanto, San Juan Capistrano,CA 92675. 1 FURTHER CERTIFY that at a meeting of the Directors of the Corporation, duly called and held on August 5,2002,at hich a quorum was present and voting,or by other duly authorized corporate action In lieu of a meeting,the following resolutions were pied: BE IT RESOLVED, that any one(1) of the following named officers, employees, or agents of this C If , whose actual signatures are shown below: NAME POSITION A U IGNATU George Scarborough City Manager ........... ................... acting for and on behalf of the Corporation and as Its act and deed be,and he or she hereby is,authorized mpower : Guaranty. To guarantee or act as surety for loans or other financial accommodations to BOYS&GIRLS CLUB F CAPISTRANO VALLEY from AMERICAN STERLING BANK("Lender") on such guarantee or surety terms as may be agreed upon between the officers or employees of this Corporation and Lender(the'Guaranty"). The amount of the Guaranty shall consist of all amounts owing under that certain promissory note dated August 5, 2002, in the original principal amount of$750,000.00 from BOYS & GIRLS CLUB OF CAPISTRANO VALLEY to Lender(the "Note"), including without limitation (a)all principal, (b)all interest, (c)all late charges, (d)all loan fees and loan charges,and (a)all collection costs and expanses relating to the Note or to any collateral for the Note. Collection costs and expenses include without limitation all of Lenders legal expenses and attorneys'fees,in addition to such sum or sums of money as may be currently guaranteed by the Corporation to Lender. Grant Security. To mortgage,pledge,transfer,endorse,hypothecate,or otherwise encumber and deliver to Lender,as security for the Guaranty, any property now or hereafter belonging to the Corporation or in which the Corporation now or hereafter may have an interest, including without limitation all real property and all personal property (tangible or intangible) of the Corporation. Such property may be mortgaged, pledged, transferred,endorsed,hypothecated,or encumbered at the time such loans are obtained or such indebtedness is incurred,or at any other time or times, and may be either in addition to or in lieu of any property theretofore mortgaged, pledged, transferred, endorsed, hypothecated, or encumbered. The provisions of these Resolutions authorizing or relating to the pledge, mortgage,transfer, endorsement,hypothecation, granting of a security interest in, or in any way encumbering, the assets of the Corporation shall include, without limitation, doing so in order to lend collateral security for the indebtedness, now or hereafter existing, and of any nature whatsoever, of BOYS & GIRLS CLUB OF CAPISTRANO VALLEY to Lender. The Corporation has considered the value to itself of lending collateral in support of such indebtedness,and the Corporation represents to Lender that the Corporation is benefited by doing so. Execute Security Documents. To execute and deliver to Lender the forms of mortgage, deed of trust, pledge agreement, hypothecation agreement and other security agreements and financing statements which may be submitted by Lender,and which shall evidence the terms and conditions under and pursuant to which such liens and encumbrances,or any of them, are given;and also to execute and deliver to Lender any other written instruments, any chattel paper, or any other collateral, of any kind or nature, which he or she may in his or her discretion deem reasonably necessary or proper in connection with or pertaining to the giving of the liens and encumbrances. Further Acts. To do and perform such other acts and things and to execute and deliver such other documents and agreements as he or she may in his or her discretion deem reasonably necessary or proper in order to carry into effect the provisions of these Resolutions. BE IT FURTHER RESOLVED,that the Corporation will notify Lender in writing at Lender's address shown above(or such other addresses as Lender may designate from time to time) prior to any (a) change in the name of the Corporation, (b) change in the assumed business name(s) of the Corporation, (c)change in the management of the Corporation,, (d)change in the authorized signer(s), (a)conversion of the Corporation to a new or different type of business entity, or (I)change in any other aspect of the Corporation that directly or indirectly relates to any agreements between the Corporation and Lender. No change in the name of the Corporation will take effect until after Lender has been notified. BE IT FURTHER RESOLVED,that any and all acts authorized pursuant to these Resolutions and performed prior to the passage of these Resolutions are hereby ratified and approved, that these Resolutions shall remain in full force and effect and Lender may rely on these Resolutions until written notice of his or her revocation shall have been delivered to and received by Lender. Any such notice shall not affect any of the Corporation's agreements or commitments in effect at the time notice is given. I FURTHER CERTIFY that the officer,employee,or agent named above is duly elected,appointed,or employed by or for the Corporation,as the case may be,and occupies the position set opposite the name;that the foregoing Resolutions now stand of record on the books of the Corporation;and that the Resolutions are in full force and effect and have not been modified or revoked in any manner whatsoever. IN TESTIMONY WHEREOF, I have hereuntomy hand on August 5,2002 and attest that the ures set opposite the names listed atwve are their genuine signatures. CE TI D TO D ATTESTED BY: X X NOTE:In case the Secretary or other certifying officer is designated by the foregoing resolutions as one a the signing officers,it is aMisable to have this certificate signed by a second Officer or Director of the Corporation. LASER PRO,Reg.U.S.Pat.8 T.M.Off.,Ver.3.29a(C)Concentrex 1999 All rights reserved.[MO-C10B E329 F3.29 BOYS.LN C1.OVLj FEb-191 r�N19d 111'>'f h1FINII IN 111 I CERTIFOITE OF INSURANCE _ • D 1sDHr, 3 I ~~ ;Yo' THIS CERTIFICATE IS ISSUE D ASA MAY 11,R Of TNI<veMA?ION r)NIV ANO (X)NFERS NO RIGHTS UPON THE CLRTIF KATE HOi n1 It THIS CFRTIFICATL DOES NOT AMEND, IXTF.ND OH AITLR ME COVI RAGF AFT ORDI 1)RY 1 HL POI(CIES BELOW COMPANIES AFFORDING COVERAGE INSURED COMPANY A — (EIIFR TIG IN;IIRANCE COMPANY BOYS AND GIRLS C[,UB (SES ZC'I-1348 --ONE VIA POSITIVA COMPANY B -� SAN JUAN CAPISTRANO, C11 92657 COMMA COMPANY C t FTTER COVERAGES __— THIS IS TO CERTIFY THAT THE POI ICIES OF INSURANCE LISTS D BELOW HAVE BFFN ISSULU TO THF INSURE D NAMED AB(WF FOR TIIL wn ICY PERIOD INDICATED, NOTWITHSTANDING ANY RE OUIREMLNI, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMI NT WITH RL!J-1 CT TO WHICH THIS CERTIFICATE MAY BF ISSUED OR MAY PERTAIN THIP INSURANCE AFFORDED HY THF POLICII S DFSCRIBLD HFRFIN B 5UI(.IFCT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIFS.LIMITS SHOWN MAY HAVE BFFN RLUtI(;FD BY PAIL)CI AIMS — CO. TYPE OF INSURANCE POLICY" NUMBER E IMM(ECTIVE DATI- EXPIF(ATION LTR 7F- (MNYDOIYY) MTt (Nf'yyD01yY) I IMI(S(In Mnuwuids) i General L labrldy 17":01AM 1 2:01AM Ger ral Agureuetes 2.)01) A ®Commercial General Liability 'I'"/ 3922044700 11/01/01 1L/01/D2 Pmdudx Comuu p/OPa Ar«gxlo—ATI}-5 20'%') Claims Made k]Ooom Pa 11.1 A AdvMlslrle I«piry 1 S _ I U i'0 Ownees a cuntrectws Prot Each Orcornaur _-- S L `� Fire Damage(Any one fire) _ $ 30C Modrorl f-, nw.(Any nn«N«i.on) f 5 Participant Le9e1 I iataliN _ __ S NCoMh Aum toobile Liability 12:01AM 12:01AM Single d A auto limit A ®Any T7 ;9"12044"J00 11/OI/U1 11/Ol/02 limit f 1.000 ®All owned aulait Bodily Scheduled nubs Injury pem n) ®Hired au1o6 BodM �. Non-ovrtled auttta Info aulden0 $_, ❑❑Garage Liability fix ly oun naes EKOpSa Liability 12:01 AM 1 2:O i AM i TT--17 (Aa. rima, uguq+a.. I A OV COVERAGE. PLUS KLH3922044B00 11/01/01 IL/O1/O2 w Other than Umbrella farm S WOO $ _.OLJ� Workers'Compensation i Statutory and 5 F« n Acadenl Employers'Llablllty $ Ileum..«T'ollq I nn 1 5 N...F ran Emni'l AD&US _ Participant Pdmary Medical s _ Accident FKcess Medleal _ $ _ WeeKly Illdem 5 -__X DESCRIPTIONOFOPERATIONS/LOCATIONSNFHK:LESIRESTRK:IIDN sPECW ITEMS CERTIFICATE HOLDER IS NAMED AS ADDITIONAL INSURED. I CERTIFICATE HOLDFR CANCEl1 ATION j SHOU1 O ANY OF THE ABOVF OF SCRIBED POLICIES HF CANCLLIFD HI-FORL THE EXPIRATION DAIL Tiff RFOF 'SIC CITY OF SAN JUAN CAPLSTRANO ISSUING COMPANY WILL ENDF-AVUR TO MAII }9_ I)AY'- ITS OFFICERS, AGENTS AND EMPLOYEE.c., WRITTEN NOTICE TO IT3E CFRT)FICATE HOIDFR NAMFTI IU 32400 PASO A DELANPO THE I FF 1, HUT FAILIIRF IO MAIL SACH NOFICE SHAI IMPf TSF SAN JUAN CAPISTRANO, CA 92675 NO OBUGAIION OR LIAHIIIIY OF ANY KINC EMON 'r1I COMPANY,I FS AGFN I: OR RFPRFSF N I ATIVFS NUTNONI/hU RfP !,1_,�IAII f ` � � v 4J POLICY NUMBER: T7 00039220"70 • CG 20 26 11 86 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED-DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Parson or Orgmbmtlon: CITY OF SAN JUAN CAPISTRANO ITS OFFICERS,AGENTS AND EMPLOYEES 32400 PASO A DELANTO SAN JUAN CAPISTRANO CA 92675 MARCO FORSTFR 25601 CAMINO DEL AVION SAN JUAN CAPISTRANO CA 92675 SAN JUAN SCHOOL ATTN: AIDA NUNUZ 31642 EL CAMINO REAL SAN JUAN CAPISTRANO CA 92675 BOYS AND GIRLS CLUB OF AMFRICA 1230 WEST PEACHTREE STREET NW ATLANTA GA 30303 CAPISTRANO UNIFIED SCHOOL DISTRICT AND BOARD OF TRUSTEES 32972 CALLE PERFECTO SAN JUAN CAPISTRANO CA 92675 MIGHTY DUCKS OF ANAHEIM NIKE/NHL STREET PROGRAM ARROWHEAD POND OF ANAHEIM PO BOX 81077 ANAHEIM CA 92B03 THE ROMAN CATHOLIC BISHOP OF ORANGE A CORPORATION SOLE OF ANY OTHER CORP. OF THE DIOCESE WHO MIGHT BE INVOLVED AND ALL THEIR OFFICERS,AGENTS AND EMPLOYEES SHALL BE INCLUDED AS ADDITIONAL INSLIRFD MISSION SAN JUAN CAPISTRANO ATTN: HOLLIS FRANKS PO BOX 697 SAN JUAN CAPISTRANO CA 92575 (It no entry appears above, information required to complete this endorsement will be shown in the Declarabom% Em iir)p lotblo to this andorsoment.) WHO IS AN INSURED (Section II) is amended to Include as an Insured the person or organization shown In tho Schedule as an Insured but only with respect to liability arising out of your operations or premises owned by or rented to you OCT-31-2001 WED 04:35 PH MAN ION BELL INSURANCE FAX NO. 213 389 5833 P. 02 • nA°�"'=A1DI ..PkSf-�[•.�_.. ;F ,t 's':�?s Ei i;,i 2'n?'`$:x4'tx' P D. ,�,e�^•`>*« o � ,w? M 10/31/01 Pvoiiuctr MANTONIBIU,INSURANCL ASSUCIA'Ilie P.O. BOX 3611515 •"e: roc L,w,. „ �4F ae 't r.3 t u: wd1L LOS ANCiF.1.t5, CA. '4056 >e•• ,t..'�y,.:Mn w '�•"_ ..as• •.Sf h�M '".,x,.4r,<< (21 i1 327-8294~ FAX k21313211-5833 L�.Y',C, p. " '4:6U•�'^.w%%'{ LIC. 7r 0655274 Incur.-J . , .., '.. ., .• y ,#.�..,y:.v_..sa=«+i Ymt'e^'. .. .ij:v' ':... Y..,.. '�F5' ,'.;y�qT� J•a.^.)'+!.�+~YAin.' Buys & Girls Clah of Capistrano Valley ;n `eq ' ' ' "" `• .,�..,,.K 51;71 F.1 C:aminn R�:il `>?ba"1;>r+t"•A Sart Tuan Cfa»slrlllu CA 92657 4 € ;.." ;1=•$ t " , t(�1�F,��' �'�r�'��^' 'Sa'�i• .E�?�a�r:J:F!..w'Si w...�,"F'" . . �»•.r.:.. A TIG Insurance "77 ''-, .:Stv�l��.fir's��1';�; ,. ?.,;:' z_ .-. ..:.a. . _a �.:.:n. . YA=•.:'i.�... .a....:w'.Cr�"'• ', _ ve>ti .. I;o COVERAGE PERIOD LTn TV PP.OP INSURANO= INCEPTION 6l MATION LIMITS A xrm4m,oteirAl UAmun 11/1/01 UNTIL rOLM;Y ISSUANIt --_OENERAL AGGREGATE $3,000,000 K uccunrcNoa F01W PRODUCTS r COMPIOP AGG $1,000,000 PERSONALS ADV INJURY $1,000,000 EACH OCCURRENCE $1,000,000 FIRE OAMAaF(Any a"tosl $50.000 MED FXV(Any on pnroom $5,000 �AUTOMOtlRC LlAtitLITY A nrvv nom 11)1/01 UNTIL POUCY ISSUANCE COMBINED SINGLE LIMIT $1,000,000 K All OVINIOAIIPIA ':CII'.IIULCb ngltlti A x uou'u wmsls:cumUtrU 1111/01 WAIL.COt.A:Y ISSUANCE BODILY INJURY UNINSURED A x 11100 N)PAVYOt 11/1101 uNT11.T•Oi,.IUY IS$VANCL MOTORIST IPer penonlaccldantl $1,000,000 ACV COMPREMCNNe I _ COLLISION LESS 1260.DEOUCTIRLE :X1;LC5 LUGn I'I Y EACN OCCURRENCE UttO0.C.LA iuRn AGGRCGATC A y y1,{ Kn+,Nu eer..a.Avoan 11/1/01 Acc=Afl COvimaF MCD LIMIT r�nMnRt' 91CKNESS CK:,1 vY OEDUCYI$LE nM"C'MiT _ OTHER PROPPRTY 11/1101 UNTIL PLODU tsSUANCE IA K RuilJin�iCUNTTiNTS/P.Qb1PM[I NT per quote hO.Ci DI'LNCObIP.WN RA IIXPBNSE per quote CUMI'M'!iV-1'1.0A'VF.R per quote Perils Insured against.- PER QUOTE DEWWWl Nor IN ItAMNaxo CAIIONYM1TII I. j.Mlscl tM., Boys and GO Ciub � '�t'L '�YF; n ^^ aT ADDITIONAL INSUREDS per schedule on file AUgIPiiVIn R7•Itl,.•'.CN1A❑VF / I n J RN-Je11 :4'> MHN I i JN kik It TWTW . . r _ _ -- - ' 7WMF---1 CERT A7E 750853 OF INSURANCE S II/06121 r.�uwa° T1118 CERTIFICATE IS IGGUCD AS A MATTER OF-INFORMATION 1C & K InsuranC6 GrU4p, Inc.,. ONLY AND CONFERS NO MOMS UPON THE CERTIFIDATE 1712 Magnavox Way IIOLVLR mis CERTIFICATE DOLS NOT AMEND. CXTCNO 013 P.O. Box 2338 ALTER THF. UOVPRAGE APPDROED BY THE POLICIES BELOW forL WDyne, In 46801 COMPANIES AFFORDING CJVERAGE CgNPANY -- 80X' AND GIRLS CLUB (B$F ?.C173k8 IFFTFR A TIG INSURANCE COMPANY^ ONE VIA FOSITIVA COMPANY g SAN JUAN CAPIST^RANO, CA 92657 LLTTPa J �� COMPANY _ LFTTr-a C THC 16 TO CERRIY THAT THE P41C0 OF INSURANCE DATED DEU1W RINE BEEN ISSUED 70 THE INSURED NAMED ABOV F" rhE FOLIC.PEAIDD IN- WARII.NOTNTKTAN01N1ANT REpW REIENL TFs1M On OONOI nOrl OF ANY CONTRACT Dn OFNEROOCUMENT WITH AMPE01"10 TYNICH TRIS CERrIFIDM VW SE IGFAIEOOAUV PEQTADI•TNC INwUrANCF.Ar-TtABDFO RVTHf 0N.10FA OFF.CAKIFI IIKRON It SUIL FO[MAIL-4F TFRM6,FXCUIK0m AND CONnI- TIONS QF ZLICN POLICES LIMITS BNOWN LIP/HAVE BEEN FIWVrEC+AY PAID CLAAM CO. TYPE OF INSURANCE POLI17y HUMRFR POLW EFPECME POLICY L"ROKIN LW RS(in Ihoucerda) LT" DATESM1D04" DAT'EMMIDDIVYJ Gceerel EleblRy Smarm r Yll f.,. 2000 A ®Pnerc nN, i°l rPnruM I.1. Jily T7 3922064700 12: 01AM 12:01AM Fmvme --Camp/ is t jQQO ❑CbimhMade IMDOW. 11/01/01 11/01/02 Personal IAIH°vlin li s V000 EIOMWI I DAnireman Rat EAeA Uvmbnce $ 1000 — A� s, 30.0 MFdiwA�eNIglDnepll-gAI u 5 FINeiDW I.1071I r�y "Osro M l.hblWlt C mamid A �U-UIililim AnyaUlA T7 3922044700 12101AM I 12:01AM Lira LIAli rimm"aims 11/01/01 11/01/02 Imh - ❑Ischlea Adu Wd H°Pd° fm aMh 1 �Non•DNAAd eaMa ur lN.71MB i _--_ -_- GueDa Llehillly Fm " _ warn ; A &,OVERAGE PLUS KLP,3922044600 1.2.01AM 12;01AN FpOmB°r ©OHin Than UmkRu krm _--.__ - 11/010- 11�1Z02- ____� ! 3000 t 3000 we rre'CAmpwuellnn 6161u ilmiT Aad S Each Aeddern EmplOyM r( AIWIIly t _ D4gaco.PAWy UYnil Dlaew-Eech Em e ADAD C Pe4lcipsal Primal MFdcsl t ANOMenI E+maec Medical ! yk-kyd nlry t X oiGcHugiow of oru-v+uS137inf3JWMFAFTYr>. ida�AatWt"rl1yv,�i'Liti%u1:Iftr:' . ._._._ . CERTIFICATE BOLDER IS NAMED AS ADDITIONAL IN51JRF.D. i 31•JOULD ANY OF TRE AROVF OFSCRIhLD FULICILS HE I CANCELLED BL/ORE w. EXPIRAriom DATE THEHEgy THE ISSUING COMPANY WILL ENDEAVOR TO MAIL ..3 -DAYS CITY OP SAN JUAN CAPISTRANO WRIT TEN NOTICE TO THF CFRTIFIGTF HOU JEH NAMED ID I HE ITS iOFFICERS, AGENTS AND ENPI.OYBI.Cs :PFT• BUT FAIT Uar-TO MAIL.SUCH NOTICE SHALL IMPOSE NO ,001.113ATION OR LIABILr OF ANY KIND UPON TNF ODMPANY• 32400 PASO A DELANTO ITS AGENTS OR firPRr ENTATFVIS SAN JUAN CAPISTRANO, CA 97.675 .y{yr warn ATb y _ I RL=D9 r. II ',IIit I'.ti' ' MANIOAELL INSURANCE ASS04ITES License 0655274 P. O. BOX 36186, LOS ANGELES, CA. 90036 0186 Phone(213)387-8294-- Fax (213)389-5833 from the desk of Ursula C. Bell January 31,2001 Meg Monahan, CMC, City Clerk City of San Juan Capistrano Via Fax to 949-493-1053 Re: Boys and Girls Club of Capistrano Valley Dear Meg! Thanks for your note of January 23 and your patience. It is our pleasure to enclose the just received endorsement per your request Feel free to call with any questions. Best regards, . • �, ate„ • 32400 PASEO ADELANTO MEMBERS OF THE CITY COUNCIL SAN JUAN CAPISTRANO, CA 92675 • �j IAbvRpn DIANE JOHNS BATHGATE (949) 493-1171 BTIS IIItl 1 1161 GEILFF COLLENE CAMPBELL (949) 493-1053 (FAX) 1776 MATT HART www.sanjuancapistrano.org DAVID M.SWERDLIN CITY MANAGER GEORGE SCARBOROUGH October 19, 2001 Mr. James Littlejohn, Executive Director Boys & Girls Club of Capistrano Valley, Inc. 1 Via Positiva San Juan Capistrano, CA 92675 Dear Mr. Littlejohn: An agreement for after school recreation services with the Boys and Girls Club of Capistrano Valley, Inc, was approved by the City Council on October 16, 2001. Evidence that the Boys and Girls Club has met the terms of the contract under Section 17. Insurance and Indemnification must be provided to our office prior to beginning work or receiving payment for work under this contract. The general liability and supplemental endorsement we have on file will expire on November 1, 2001. We also lack any evidence of comprehensive automobile coverage as required. I have enclosed a copy of Page 6 of the contract for your reference. An executed original contract will be issued to you after this evidence is received. If you have questions specific to insurance requirements, please contact Dawn Schanderl, Deputy City Clerk (949) 443-6310. If you have questions specific to this agreement, please contact Karen Crocker, Community Services Manager (949) 443- 6389. Sincerely, Meg M aha , CMC City Cl rk it enclosure. age 6 of agreement cc: Karen Crocker, Community Services Manager ; Al King, Community Services Director DIIUG USE FS S(w lir m C'orrititrmin: Provrr w,I flu, Poo to rIlhomIhc Ufw,rn' FAX CORRESPONDENCE/TRANSMITTAL TO: Ursula C. Bell, Manion/Bell Insurance Associates: Fax— (213) 389-5833 FROM: Meg Monahan, CMC, City Clerk (949) 443-6308 RE: Boys & Girls Club of Capistrano Valley DATE: January 23, 2002 Dear Ms. Bell: I was remiss in not mentioning this earlier, as I was not aware that we have numerous agreements with Boys and Girls Club. We need one more document to bring our insurance records current for the Boys and Girls Club. I have attached a copy of the endorsement that you provided last year. Would you please fax and follow via mail a document that brings this endorsement current. Thank you very much for your assistance. Feel free to contact me with questions. attached: Additional insured endorsement on form CG 20 26 11 85 FAX CORRESPONDENCE/TRANSMITTAL TO: Ursula C. Bell, Manion/Bell Insurance Associates: Fax— (213) 389-5833 FROM: Meg Monahan, CMC, City Clerk (949) 443-6308 RE: Boys & Girls Club of Capistrano Valley DATE: January 7, 2002 Dear Ms. Bell: I have been provided your name through the Capistrano Valley Boys & Girls Club to pursue the required evidence of insurance. This evidence is overdue. Therefore, I would greatly appreciate your help in getting this completed. The agreement that the Boys & Girls Club of Capistrano Valley has with the City of San Juan Capistrano includes specific requirements for various forms of insurance coverage. Evidence of this coverage is also required to be kept current . The evidence related to general liability and automobile liability insurance lapsed over two months ago. Please provide us updated evidence, including the liability endorsement form as noted under Section 17: Insurance & Indemnification. Feel free to call me with any questions. Thank you very much for your assistance. attached: Section 17. Insurance and Indemnification Lapsed certificate of liability insurance - -7 cd4lt �� a/3 - 387_ ��g� SECTION 17. INSURANCE AND INDEMNIFICATION. Contractor shall submit to the City: • A certificate of general liability insurance naming the City as additional insured in the amount of$1,000,000 per occurrence; • A liability endorsement form with reference to the above-listed liability insurance; • Proof of workers' compensation insurance for all employees; • Comprehensive automobile liability coverage for owned, hired and non- owned vehicles in the amount of $1,000,000 package coverage including bodily injury, property damage and uninsured motorist. Contractor shall indemnify, defend, and hold harmless the City and its officers and employees against all liabilities orclaims of liability or loss(including reasonable attorney's fees, related costs and expenses) because of death, personal injury or property damage arising or resulting from the fault or negligence of Contractor in its operations under this Agreement. SECTION 18. CONFLICT OF INTEREST. Contractor must certify that to the best of its knowledge, no City employee or office of any public agency interest has any pecuniary interest in Contractor's business and that no person associated with Contractor has any interest that would conflict in any manner with the performance of duties specified as a part of this project. Contractor represents that it presently has no interest and shall not acquire any interest, direct or indirect, which could conflict in any manner or degree with the faithful performance of this project. C\MyFilesWtlm In Policies\Boys and Girls Club agreement 2001 02.wpd Page 6 OCT-23-2001 10.38 MANION BEL[ F' 1�2iF12 x rAT 101232001 wA er:',t Producer THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION INANION/DELI,TNSintp Nci,ASSOCLhTPS ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P. 0. BOX 36186 HOLDER.THIS CERTIFICATE DOES NOT AMEND.EXTEND DR LOS ANGETA S,CA-90036 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW — (213)367-8294'FAX (213)389-5833 OOMPANIE9 AFFORDING COVEFLAOES LIC.//0655274 A MARKEL INSURANCE COMPANY --_- C.mP..Y BOYS ANDGTFISCLIMCFrAPLYTRANOVAf1.BY B _ — 31371 RL CAMINO RRAL CumP nv SAN IVAN CAPISTRANO,CA.92615 G —- CempAM D P-°^�'„ tx -�. A A e JIw ^� wb X - 1 +41,x, A ' pll"a•"� °' r1.tT,$T ,�u�1"w 6�1e.� .. ,�T'+ ,•5 t°ieww, y:,-' i ?.5'6 ,}�..:r , n ., LRwl!J,:�J...r�w_c-:r'�w£'.rt�'.,u.A.�i4 n--t.�A w�'S�..rTY.�rS:tN.lF_tlS'4� r�'4"i �f X✓-"tA .1' I'f...r +4n- S.Mt._. A THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LIMO BELOW HAVF BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POL DY PERIOD INDICATED,NOTWITH4ANDINO ANY REQUIREMENT.TERM OR CONDITION DF ANY CONTRACT OR OTHER DOCUMENT WDR R[SPf CY TO WHICH THIS CFNIIFICATE MAY BE ISSUED OR MAY PERTAIN-THE INSURANCE AFFORDED RV THE POLICIES DfISMVIED HEA[IN Is SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITION.OF SUCH POLICIES. LIMITS SHOWN MAY HAVE PEEN REDUCED BY PAID CLAIMS — CO roUcr LTR TYPE OF MBUPAMC! NUMBFA INCEPTION pgeAg6N A cDMM.OFHH�a LMelun R50-2C'Y009J83 11/1/2000 11/1/2001 GENERALAGGREGATE 33.000,000 00 DccUWMCE Fawo PRODUCTS-COM PIOP AGG 31,000,000.00 Owrn PERSONAL ✓y ADV INJURY _ — _81.000,000 00 EACH OCCURRENCE_ ._ .— $1__000,000 00 FIRE DAMACE(ADY pR.fila[ i8S0_00 00 (EXCLUDING MEM111W AND STAFF) _ ME O EXPIAnv M.p.-.11 $5,000.00 AUTOMOBILE LIABILITY A Anv AMD — COMBINED SINGLE LIMIT31.000.000.00 X AU Ovnan.Lrrac 100-2CY-018-688 11/1/2000 I1/1/2001 _— .-- — PLNLOLOFOADTOS — �mIEDALnp�; I00-2CY4)IS-"8 11/1/2000 11/1_/2001 a NOx.�wvEO ALnD. 100-2CY-019-668 11/1/2000 21/1/2001 IXCESS LIAXIIITY EACH OCCURRENCE _-. uM1eRLAlULH aDGRFTIATE _.—__ _— � -_.� — ACOIDENT CDVNAOE WE LIMIT MIMAM SICKNESS_ ��yn DEDucTlBlf -- ,_ . "DUCTKk OFICRIPLpa OF OR]FILTOWrtOCATONaryEMCLEXIaNFCMI REM( _— �- -- -- -- — Certificate Holder is included as additional insured but only as respects the operations of the Named Insured performed. Re, After School Recreation Programs/Real Property Lease Agreement :.yk Nvb"i*':�vt'S1gAm.�Erl'•"�w 6 d. -i'>- .�"1. p+b"I n-;A A vn A'w�`_+�yx'"'^4°*"'�,: 'T.°: , STs 3.OULD ANY OFTNE AILUVP.neaCRIPFO PuUCITI RL CAN"LL�b BEFOUL!TRP City of San Juan Capistrano EXPIRATION DAIP TBERPOF.THE M,UINO U)MPANY WHA,MA11.100AY1 it's officers, agents and employees WN TEN Nm ICU TO IHV CER'DHCATE HOLDPR NAMED TO THE LEFT(-rcpt 32400 Paso A Delanto ino Mc of non-p.ywcnl ref pFc=i when:.L a 10 duy radia.WL71 San Juan Capistrano, CA 92675 IMLi..n)- AUTNONLC[ bINi ATIV L /,( 1111 Rl F'.R2 ACORgR CERTIFICAfF INSURANCE L0 ISSUE�ATE(AAN,DD Y, 1 1-17-2000 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS Markel Insurance Company NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, P.O. BOX 3870 EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Glen Allen, VA 23058-3870 COMPANIES AFFORDING COVERAGE COMPANY CODE SUB-CODE LETTER A MARKEL INSURANCE COMPANY COMPANY O INSURED LETTER B It � , Boys &Girls Club Of Capistrano Valley COMPANY I z_-,-„2 ^� C _ / �I` 4 T 31371 EI Camino Real LETTER L l n-<? ,< m San Juan Capistrano, CA 92675 COMPANYrn D LETTER fTl COMPANY E _ 24 3 LETTER —• 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 O POLICY EFFECTIVE POLICY EXPIRATION TR TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YY) DATE(MM/DDNY) LIMITS A GENERAL LIABILITY GENERAL AGGREGATE s 3,000,000 X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OPS AGGREGATE $ 1,000,000 CLAIMS MADE 1E OCCUR. 8502CY009485-6 11-01-2000 11_01-2001 PERSONAL&ADVERTISING INJURY $ 11000,000 OWNERS&CONTRACTOR'S PROT. EACH OCCURRENCE $ 1,000,000 FIRE DAMAGE(Any one)ire) $ 100,000 MEDICAL EXPENSE(Any one person) s 5,000 AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per Person) s HIRED AUTOS BODILY INJURY s NON-OWNED AUTOS (Per accident) GARAGE LIABILITY PROPERTY DAMAGE s EXCESS LIABILITY EACH OCCURRENCE s UMBRELLA FORM AGGREGATE 8 OTHER THAN UMBRELLA FORM STATUTORY LIMITS WORKER'S COMPENSATION EACH ACCIDENT 9 AND DISEASE-POLICY LIMIT a EMPLOYERS'LIABILITY DISEASE-EACH EMPLOYEE $ A OTHER Inland Marine Property 8502CY009485-6 11-01-2000 11-01-2001 DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/BPECIAL ITEMS Certificate holder is included as additional insured as lessor of premises. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO City of San Juan Capistrano MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION its officers,agents and employees OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR 32400 Paso A Delanto REPRESENTATIVES. San Juan Capistrano, CA 92675 AUTHORI2ED REPRESENTATIVE Bruce A. Kay ELE ACORD 25-5(V90) =o(0)ACORD-.CORP 01/20/1974 13:08 M/B MANION/BELL INS.**** 06508449 P•03 �R: .• • M 'POLICY NUMBER: 880WY008488 - 6 COMMERCIAL GENERAL LIABILITY' THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MANAGERS OR`LESSORS"OF PREMISES h This endorsement modifies insurance provided under the following: a. COMMERCIAL GENERAL LIABILITY COVERAGE PART. T. ' SCHEDULE 1. Designation of Premises(Part Leased to You): 31371 EI Camino Real, San Juan Capiatrano,CA 92693 2. Name of Person or Organization (Additional Insured): City of Sen Juan Capistrano 31 Its officers, agents and employees 3. Additional Premium: Included (If no entry appears above, the Information required to complete this endorsement will be shown In the :D9aWa ions as applicable to this endorsement.) JgJ�. WHO IS AN INSURED (Section IU is amended to This insurance does not apply to: 11nolude as. an Insured the person or organization ° shown In the Schedule but only with respect to 1• Any "occurrence" which takes place after you liability arising out of the ownership, maintenance or cease to be a tenant ih that premises. use of that part of the premises leased to you and shown In the Schedule and subject to the following 2. Structural alterations,ions now construction by tion or demolition operations performed by or on behalf of the person or organization shown In the Schedule. ;J.? WE CG 20 11 01 96 Copyright, Insurance Services Office, Inc., 1994 32400 PASEO ADELANTO �,,y MEMBERS OF DIAEB CITY L. CWNCIL SAN.JUAN CAPISTRANO,CA 92675 /{:Y NHMMm, GATE COLLENE CAMPBELL (949)493-1171 FRHUfFF, 1961 JOIN GREINER (949)493-1053 (FAX) 1776 WYATT HART DAVID M.SYIEROLIN CITY MANAGER GEORGE SCARBOROUGH October 11, 2000 Mr. Jim Williams, Executive Director Boys & Girls Club of Capistrano Valley 1 Via Positive San Juan Capistrano, Calif orr?ia 92675 Re: Renewal of General Liability and Endorsement Form (Real Property Lease Agreement/Youth Services Facility) Dear Mr. Williams: The General Liability Certificate of Insurance, regarding the above-referenced agreement, is due to expire on November 1, 2000. 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. Please forward the updated certificate and endorsement to the City, attention City Clerk's office, by the above due date. If you have any questions, please contact me at (949) 443-6310. Thank you for your cooperation. Very truly yours, ,Q�. Dawn M. Schanderl Deputy City Clerk cc: Cheryl Johnson, City Clerk Karen Crocker, Community Services Manager DRUG USE IS San Juan Capistrano: Preserving the Past to Enhance the Future NOV-23-1999 TUE 12:42 PM MANION BELL INSURANCE FAX N0, 213 389 5833 P. 03 1028!99 Producer THIS CLE TIFICATE IS ISSUED AS A MATTER OF INFORMATION MAN(ON/DELL INSURANCH ASSOCIATP3 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P. 0. BOX 36186 HOLDER_THIS CERTIFICATE DOES NOT AMEND,EXTEND OR LOS ANGELES, CA_ 90036 ALTER THE COVERAGE AFFORDED RY THE POLICIES BELOW _ (213)387-8294*FAX(213)389-5833 COMPANIES AFFORDING COVERAGES _ LIG.N 0655274 Como NY A MARKEL INSURANCE COMPANY BOYS AND CIMS CLUB Or CAPISTRANO VALLEY 6 31371 EL CAMINO R511. C.I P..Y SAN IDAN CAPISTRANO,CA.92675 C _ wD :OV THISIS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW NAVE SEFIN ISSUED TO THE INSURED NAMED ARDVE FOR THE POLICY PERIOD INDICATED,NOTW ITHSTANDLN.ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CCRTIPCAYE MAY DE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDCD RY Tx[POLICIES QESCRIBEO MERLIN IS SUWECT TD ALL Yxt TERMS, EXCLUSIONS AND CONDITION$OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, co POLICY LTA TYPE of INSURANCE NUMaeA INCEPTION CYNyYIPN A co.N.OrxrnAl LAOLIIY 850.2CY009d85 11/1/99 11/1/00 GENERAL AGGREGATE _ $3.000,000.00 ncewlemcL fpnw PRODUCTS'COMP/OP qGG ^� 11,000.00p,00 Umrn PERSONAL IS ADV INdunr $1,000.000.00 EACH OCCURRENCE 11.000,000.00 FIRE DAMAGE(ANY one tical _ _650.000.00 (EXCLUDING ME.MlFAS AND STAFF) MEO EXP(A,Y on*parson! Y 15,000.00 AUTOMOBILE WAAILITY _ .HY AUTO COMBINED SINGLE LIMIT ALL nwNEO AUms BODILY INJURY w NCHEOULFn AUT01 (Per Par_od morn AUms BODILY INJURY NON O WNrD AUTON (Per..C,dencl ACV CumOraHareev*IS CODIBIaA les. 1 250.Oeductmle SCHEDULED VEHICLE SHOWN BELOW PROPERTY DAMAGE _ EXCESS LIABILITY EACH OCCURRENCE .FRULLA ILIUM A0OAEOATE , OTIILE THAN UMRLLA rORM ACCIDENT COVERAGE MED LIMIT I'Nrwnnr SICKNESS IICE" DEOUCT.EU OFOVL,LILE on4LR nf[CRITOx L><PRR1iR1N{ILOCAl1nYYNFNaLIfli1[C1LL IiFYR ' Certificate Holder is included as additional insured but only as respects the operations of the Named Insured performed. Re: After School Recreation Programs/Real ProperEy Lease Agreement ER FI I'CiATE Ylt7taDER A — � 77, t:C'RYI� QlY1 ' + a a , _u SHOULD ANY CFTRE ABOVE Dt,NCRIRED POLICID5 RE CANCELED DRmrtE THE City of San Juan Capistrano EXIMATON DAL L Tin R FDF,TRE ISSUING COMPANY WILL AVAIL 30 DAYS it's OffiCI agents and employees WRITTEN NOTICE TOTHE CLRTIMCATE IIOLUER NAMED lO 712 LeFr(=<:.M 32400 Paso A Delanto uL case ofonn-paymenL ofpremiw4 wherein a lO day Potico Will San Juan Capistrano, CA 92675 be ivcn). AUTIIOMAD ALMLSENTATIVE NOV-23-1999 TUE 12:42 PM MANION BELL INSURANCE FAX NO. 213 389 5833 P. 34 .POLICY NUMBER: 8602CY000485 COMMERCIAL GENERAL I IASILITY 1 ! THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULL . ADDITIONAL INSURED -- DESIGNATED PERSON R ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEOULE Name of Person at Organization. City of Sen Juan Capistrano its officers, agents and employees (If no entry appears above, information required to complete this endorsement will be shown ii the Declarations as applicable to this endoraementJ WHO IS AN INSURED (Section II) Is amended to Include as an Insured the person or organization shown in the Schedule as an Insured but only with respect to liability arising out of your operations or premises owned by or rented to you. CG 20 26 11 85 Copyright, Insuranca jervIcss Office, Inc., 1984 IP • • SG STATE P.O. BOX 807, SAN FRANCISCO,CA 94101-0807 ��t��• P `2D COMPENSATION INSURANCE FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE POLICY NUMBER: 1381384 - 02 ISSUE DATE: 01-01-02 CERTIFICATE EXPIRES: 01-01-03 CITY OF SAN JUAN CAPISTRANO JOB: ALL OPERATIONS BUILDING L SAFETY DEPARTMENT 32400 PASEO ADELANTO SAN JUAN CAPISTRANO, CA 92675 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 10days' advance written notice to the employer. We will also give you 10 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 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. PRESIDENT�•I/t EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: 81,000,000.00 PER OCCURRENCE. v sy s C z rn z> ca rn rn v _ d EMPLOYER LEGAL NAME _ BOYS AND GIRLS CLUB OF CAPISTRANO BOYS AND GIRLS CLUB OF CAPISTRANO VALLEY VALLEY (A NON-PROFIT PUBLIC BENEFIT CORP) 1 VIA POSITIVA SAN JUAN CAPO CA 82875 12-IS-01 PRINTED: P0408 THIS DOCUMENT HAS A BLUE PAT TERNED . SG STATE P.O. BOX 807, SAN FRANCISCO,CA 94101-0807 COMPENSATION INSURANCE FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE " POLICY NUMBER: 1381384 - 01 ISSUE DATE: 01-01-01 CERTIFICATE EXPIRES: 01-01-02 CITY OF SAN JUAN CAPISTRANO JOB: AFTER SCHOOL RECREATION ATTN CITY CLERK'S OFFICE PROGRAMS REAL PROPERTY 32400 PASEO ADELANTO LEASE AGREEMENT SAN JUAN CAPISTRANO CA 92675 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 10 days' advance written notice to the employer. We will also give you 10 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 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. PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000.00 PER OCCURRENCE. EMPLOYER LEGAL NAME BOYS ANO GIRLS CLUB Of CAPISTRANO BOYS AND GIRLS CLUB OF CAPISTRANO VALL VALLEY - 1 VIA PpSfTIVA (A NON-PROFIT PUBLIC BENEFIT CORP) SAN JUAN CAPISTRANO CA 92675 PRINTED: 12-18-00 P0408 � a � STATE P.O. BOX 420807,SAN FRANCISCO, CA 94142-0807 COMPENSATION N S U R A N C E FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE JANUARY 4, 2000 00 POLICY NUMBER* 1381364 - 1-1-01 CERTIFICATE EXPIRES: F- CITY OF SAN JUAN CAPISTRANO ATTR CITY CLERK'S OFFICE 32400 PASEO ADELANTO SAN JUAN CAPISTRANO CA 92675 JOB: AFTER SCHOOL RECREATION PROGRANSIR£AL PROPERTY LEASE AGREEMENT 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 ten days'advance written notice to the employer. We will also give you TEN 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 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. AUTHORIZED REPRESENTATIVE PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: 91,000,000 PER OCCURRENCE. c 2Ar�*I l7 vl A �--1 ro ti Oil r �u m� Ort m 2 ~ v - EMPLOYER S^ F- BOYS AND GIRLS CLUB OF CAPISTRANO VALLEY 31371 EL CAMINO REAL SAN JUAN CAPISTRANO CA 92675 THIS DOCUMENT • Jwwn 32400 PASEO ADELANTO MEMBERS OF THE CIN COUNCIL SAN JUAN CAPISTRANO, CA 92675COLLENE CAMPBELL (949)493-1 171 / ulluptll(1 JOHN GREINER JOHN MART (949) 493-1053 (FAX) (HILIBN 1 1961 GIL JONES 1776 DAVID M.SWERDLIN CITY MANAGER GEORGE SCARBOROUGH December 27, 1999 Mr. James L. Williams, Executive Director Boys and Girls Club of Capistrano Valley 31371 EI Camino Real San Juan Capistrano, California 92675 Re: Renewal of Workers' Compensation Certificate of Insurance (After School Recreation Programs/Real Property Lease Agreement) Dear Mr. Williams: The Workers' Compensation Certificate of Insurance, regarding the above-referenced agreements, is due to expire on January 1, 2000. In accordance with your agreements, the insurance certificate needs to be renewed for an additional period of one year. Please forward an updated certificate to the City of San Juan Capistrano, attention City Clerk's office, by January 10, 2000. If you have any questions, please contact me at (949) 443-6310. Thank you for your cooperation. Very truly yours, Alta &64Z Dawn M. Schanderl Deputy City Clerk cc: Cheryl Johnson, City Clerk Karen Crocker, Community Services Manager DRUG Is MUMEW San Juan Capistrano: Preserving the Past to Enhance the Future �. sk xyr`Tw`lk`k)<�.`£:.�'b.�l,`I Fx`.i1�`(� C , \b. •: ,a,,., v h �` :.... z 'Cb':J.a?a'ig&?>-2 G,a";� .`.��^.z'io<£�bhb ¢.'L' £: 10/28/99 Producer THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION MANION/BELL INSURANCE ASSOCIATES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P. O. BOX 36186 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR LOS ANGELES,CA. 90036 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW (213)387-8294*FAX(213)389-5833 COMPANIES AFFORDING COVERAGES LIC.1110655274 Company Insured A MARKEL INSURANCE COMPANY Company M �� BOYS AND GIRLS CLUB OF CAPISTRANO VALLEY B �/lJ 31371 6L R Company SAN JUAN CAPISTRANO, �Q^ CA.92675 C Company D e`h�b�b b :.3h`Cb"o@b£b".brc?' 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 POLICY LTR TYPE OF INSURANCE NUMBER INCEPTION EYPVOLTUN LIMITS A JC.MM.OP.EFAIMBRDY 850-2CY009-485 11/1/99 ll/l/00 GENERAL AGGREGATE $3,000,000.00 OCCURRENCE FORM PRODUCTS•COMP/OP AGG $1,000,000.00 orHER PERSONAL&ADV INJURY $1,000,000.00 EACH OCCURRENCE $1,000,000.00 FIRE DAMAGE(Any one fire) $50,000.00 (EXCLUDING MEMBERS AND STAFF) MED EXP(Any One person) $5,000.00 AUTOMOBILE LIABILITY ANY Aura COMBINED SINGLE LIMIT ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NONOWNEDAUTOS (Per accident) ACV Comprehensive&Collision less $250.Deductible SCHEDULED VEHICLE SHOWN BELOW PROPERTY DAMAGE .BC EXCESS LIABILITY EACH OCCURRENCE C A —:T UMBRELLA FORM AGGREGATE y OTHER THAN UMBRELLA FORM ACCIDENT COVERAGE MED LIMIT N�3r FP'MARv SICKNESS Ata'='U C2 IFF ExCYEE DEDUCTIBLE _ .,DUCT'LLE OTHER � La DESCMPTON OF OPERATONSILOCATIONINEHIMES/SPECIAL REMS Certificate Holder is included as additional insured but only as respects the operations of the Named Insured performed. Re: After School Recreation Programs/Real Property Lease Agreement « $ .... `.':at;..;&x::ri4A<v::..:zx>Fi?rv:£i::,.:E:;Sie�r . LF.. ':D@'E;..:..�.�a3$:£..,.,.ore:Ytx..�'...xo.:��.. .,,,T..::�b<'.:�w��..:xzb.<h�.c<x�xh'.h...:;,bc'.hh.` xt`ar.,...,>:cx'rix•:x,:::�:z SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELED BEFORE THE City of San Juan Capistrano EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL MAIL 30 DAYS it's officers, agents and employees WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT(except 32400 Paso A Delanto in case of non-payment of premium wherein a 10 day notice will San Juan Capistrano, CA 92675 be given). AUTHORIZED REPRESENTATIVE ,POLICY NUMBER: 8602CIO09485 COMMERCIAL GENERAL (ABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULL . ADDITIONAL INSURED -.. DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: City of Sen Juan Capistrano its officers, agents and employees (If no entry appears above, information required to complete this endorsement will be shown i) 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 as an insured but only with respect to liability arising out of your operations or premises owned by or rented to you. CG 20 26 11 86 Copyright, Insurance Services Office, Inc., 1984 ❑ C ACORgFI CERT0 AT INSURANCE ISSUE DATE(MM/DD/VV) 11-17-1998 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS Markel Insurance Company NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, P.O. Box,3870 EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Glen Allen, VA 23058-3870 COMPANIES AFFORDING COVERAGE COMPANY CODE SUB-CODE LETTER A MARKEL INSURANCE COMPANY z COMPANY B INSURED LETTER W Y [n Boys&Girls Club of Capistrano Valley COMPANY C 31371 EI Camino Real LETTER San Juan Capistrano, CA 92675 COMPANY D v _ _e_ O < LETTER N R] COMPANY E -= LETTER 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 SUN POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY Co POLICY EFFECTIVE POLICY EXPIRATION TR TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YY) DATE(MM/DD/YY) LIMITS A GENERAL LIABILITY GENERAL AGGREGATE $ 3,000,000 X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OPS AGGREGATE s 11000,000 CLAIMS MADE OCCUR. 8502CY009485-4 11-01-1998 11-01-1999 PERSONAL 6ADVERTISING INJURY 0 1,000,000 OWNERS A CONTRACTOR'S PROT. EACH OCCURRENCE $ 1,000,000 FIRE DAMAGE(Any one fire) $ 100,000 MEDICAL EXPENSE(Any one person) s 5,000 AUTOMOBILE LIABILITY COMBINED SINGLE ANY AUTO LIMIT s ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Par Person) s HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accidentl s GARAGE LIABILITY PROPERTY DAMAGE 3 EXCESS LIABILITY EACH OCCURRENCE s UMBRELLA FORM AGGREGATE 8 OTHER THAN UMBRELLA FORM WORKER'S COMPENSATION STATUTORY LIMITS AND EACH ACCIDENT $ DISEASEPOLICYLIMIT S EMPLOYERS'LIABILITY DISEASE-EACH EMPLOYEE S A OTHER Crime 8502CY009485-4 11-01-1998 11-01-1999 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS Certificate holder is included as additional insured for operations conducted by the named insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO City of San Juan Capistrano MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION its officers, agents and employees OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR 32400 Paso A Delano REPRESENTATIVES. San Juan Capistrano, CA 92675 AUTHORIZED REPRESENTATIVE 00 Bruce A. Kay (st,. VPO ACORD 25-517/901 Icl ACO CORPORATION 1990 POLICY NUMBER: 8502CYO*85 - 4 WMMERQAL GFKIGPA4 LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: my n c COMMERCIAL GENERAL LIABILITY COVERAGE PART. _> L m SCHEDULE m_ Name of Person or Organization: P City of San Juan Capistrano its officers, agents and employees cn' m (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 as an insured but only with respect to liability arising out of your operations or premises owned by or rented to you. CG 20 26 11 85 Copyright, Insurance Services Office, Inc., 1984