1996-1108_CAPITAL & COUNTIES USA_Insurance Certificate — • ,
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A4,11ItIL ,1110E.R.:,ITHIF.„10,A-THERO.F91/41: SURAN: '
PROPOOE41HiSCRiiHCA1E IS ISSUED AS A MATT O INFORMATION
ONLY AND CONFERS NO RIGHTS UPON Tlik. CERTIFICATE
Anderson and Anderson/LA HOLDER. THIS CERTIFICATE DOES NOT AMErfaiVEI(TENDLiOC4 d
Insurance Brokers , Inc . ALTER THE COVERAGE AFFORDED BY THE POLICIES0CCEBIITEpTCLAOR01_cW:Flii.smEsTE7NNATNe
801 N. Brand Blvd. , Ste 1050 COMPANIES AFFORDING COVERAGE
Y
Glendale , CA 91203 COMPANY
818-637-8600 A Fireman's Fund Insurance Co.
-INSURED COMPANY
Capital & Counties USA, Inc . B (OM 3r)
101 California Street COMPANY
San Francisco , CA 94111 C afilleine)k±
COMPANY
CAYRA030iMgMMNWMMENgPWOAMMRAWWWgWEUWWMM:AOMWMAgMMfflgiWmagNR865aimmm
THISISTOCERTIFY THAT THE POLICIESOFINSURANCE LISTEDBELOWHAVE BEENISSUED TO THEINSURED NAMED ABOVEFORTHEPOLICY PERIOD
INDICA T ED,NOT WIT HST ANDINGANYREOUIREMENT,T ERMORCONDITIONOE ANY CON T PACT ORO T HERDOCUMENT WITHRESPECT TOWHICHTHIS
CERTIFICATE MAY BE ISSUED ORMAY PERT AIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MA Y HAVE BEEN REDUCED BY PAID CLAMS.
CO POLICY EFFECTIVE POLICY EXPIRATION
TYPE OF INSURANCE POLICY NUMBER LIMITS
LTR DATE(MMIDDM) DATE(MMIDWYNI
GENERAL LIABILITY GENERAL AGGREGATE $ 2,000,000
A x COMMERCIAL GENERAL LIABILITY MXX80659174 11/01/96 11/01/97 PRODLCTS.COMP/OP AGG $ 2,000,000
CLAIMS MADE X OCCUR PERSONAL T. ADV INJURY $ 1 ,000,000
OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ 1 „0 0 0,000
FIRE DAMAGE(Any one lire) $ '100 000
MED EXP(Any one pe(son) 10,000
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
ANY AUTO
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person)
HIRED AUTOS BODILY INJURY $
NON.OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
GARAGE LIABILITY AUTO ONLY -EA ACCIDENT
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EXCESS LIABILITY EACH OCCURRENCE $
UMBRELLA FORM AGGREGATE
OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND STATUTORY LIMITS
EMPLOYERSLIABILITY EACH ACCIDENT
THE PROPRIETOR/
INCL DISEASE POLICY LIMIT $
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL DISEASE.EACH EMPLOYEE $
OTHER
DESCRIPTION OF OPER AT IONSILOCATIONSIVEH ICLESISPEC IAL ITEMS
It is agreed that the certificate holder is named as Additional Insured with
respect to project: Lot 216 , Tract 12954. The attached Additional Insured
endorsement applies .
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
City of San Juan Capistrano 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
32400 Paseo Adel an to BUT FAILURE TO MAIL SUCH NOTICE SH ALL IMPOSE NO OBLIGATION OR LIABILITY
San Juan Capistrano CA 92675 OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
AUT IZED REPRESENTATIVE 412093000
-\JfIr WV—
POLICY NUMBER COMMERCIAL GENERAL L.ABiL, ti
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 Person or Organization:
The City of San Juan Capistrano, the Community Redevelopment
Agency , its elected or appointed officers , officials , employees
and volunteers .
•
(1f 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.
•
•
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CG 20 2611 85. Copyright, Insurance Services Office. Inc.. 1984
•
.4w% 0
toe .
I Y MEMBERS OF THE CITY COUNCIL
111 COLLENE CAMPBELL
U WYATT HART
m�oero,AIEB GILJONES
• B'�t76�o 1961 CAROLYN NASH
DAVID SWERDLIN
• (( • CITY MANAGER
November 5, 1996 GEORGE SCARBOROUGH
Mr. Derek Aynsley
Marbella Plaza Partners
101 California Street
San Francisco, California 94111
Re: Renewal of General Liability Certificate of Insurance (License Agreement.
Lot 216. Tract 12954)
Dear Mr. Aynsley:
The General Liability Certificate of Insurance, regarding the above-referenced project, expired on
November 1, 1996. In accordance with your agreement, the insurance certificate needs to be
renewed for an additional period of one year. The agreement requires a general liability endorsement
form naming the City of San Juan Capistrano as an additional insured. I have included a City
approved endorsement form to submit to your insurance company; however, your insurance company
may provide their own endorsement form.
Please forward the updated certificate and the endorsement form to the City, attention City Clerk's
office, by November 20, 1996.
If you have any questions, please contact me at (714) 443-6310.
Thank you for your cooperation.
Very truly yours,
)060Qh 0/0/ant
Dawn M. Schanderl
Deputy City Clerk
Enclosure
cc: Cheryl Johnson, City Clerk
Sam Shoucair, Senior Engineer
32400 PASEO ADELANTO, SAN JUAN CAPISTRANO, CALIFORNIA 92675 • (714) 493-1171