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1995-1102_CAPITAL & COUNTIES USA_Insurance Certificate DATE(MM/DD/YY) EI�� 'IFI . �' I UR NC 11/02/95 PRODUCIR THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE Sullivan&Curtis Ins. Brokers DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE 2100 Main Street#350 POLICIES BELOW. Irvine,CA 92714 COMPANIES AFFORDING COVERAGE COMPANY A CHUBB GROUP INSURED COMPANY COMPANY Capital&Counties USA Inc. c 101 California St.,#2.525 COMPANY San Francisco CA 94111 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITIISTANDING 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. COI POLICY EFF. POLICY EXP. ITR TYPE OF INSURANCE POLICY NUMBER LIMITS DATE(MM/DD/YY) DATE(MM/DD/YY) GENERAL LIABILITY GENERAL AGGREGATE 2000000 COMM.GENERAL LIABILITY PROD-COMP/OP AGG. x .35307721 11/01/95 11/01/96 1.11.14.1 'CLAIMS MADE n OCCUR PERS.&ADV.INJURY 1000000 OWNER'S&CONTRACT'S PROT EACH OCCURRENCE 1000000 FIRE DAMAGE(One Flre) 100000 MED EXP(Any one person) 10000 AUTOMOBILE LIABILITY COMBINED SINGLE ANY AUTO LIMIT ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) IIIRED 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 LIABII,ITY EACH OCCURRENCE UMBRELLA FORM AGGREGATE OTHER THAN UMBRELLA FORM WORKERS COMPENSATION AND (STATUTORY LIMITS EMPLOYERS'LIABILITY - - -•--• • EACH ACCIDENT THE PROPRIETOR/ — [NCI, PARTNERS/EXECUTIVE DISEASE-POLICY LIMIT OFFICERS ARE: EXCI, DISEASE-EACH EMPL. OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS RE: LICENSE AGREEMENT, LOT 216,TRACT 12954 SEE ATTACHED CG2010 FOR ADDITIONAL INSURED INFORMATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE CITY OF SAN JUAN CAPISTRANO EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL 111111111111111116 MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE DEPT. OF ENG. &BLDG. LEFT,dilailliONMeadillakillirIDM 32400 PASEO ADELANTO AUTHORIZE EP ESENTATIVE SAN JUAN CAPISTRANO, CA 92675 /-,77/(1 (.,U) POLICY #35307721 - ^' "L 2L •cnML _,hG.�, THIS ENDOF HENT CHANGES THE POLICY. P SE READ IT CAREFULLY. ADDITIONAL INSURED -- OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: CITY OF SAN JUAN CAPISTRANO (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of "your work" for that insured by or for you. CG 20 10 11 85 Copyright, Insurance Services Office, Inc., 1984 J'tO'' • C, � I �" MEMBERS OF THE CITY COUNCIL 4 COL ENE CAMPBELL !!! WYATT HART DRUG USES 1 4,.imsaavaaarta GILJONES IS !siasusnED 1961 CAROLYN NASH BI ' 1776 /� OAVIOSWEROLIN October 31 1 995 • `� • CITY MANAGER GEORGE SCARBOROUGH Capital & Countries USA, Inc. 101 California Street, #2525 San Francisco, California 94111 Re: Renewal of General Liability Certificate of Insurance (License Agreement. Lot 216, Tract 12954. Wonderyears Preschool) Gentlemen: The General Liability Certificate of Insurance, regarding the above-referenced License Agreement, is due to expire on November 1,1995. In accordance with your agreement, the insurance certificate needs o 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 16, 1995. If you have any questions, please contact me at (714) 443-6310. Thank you for your cooperation. Very truly yours, caLLch. Dawn M. Schanderl Deputy City Clerk Enclosure cc: Cheryl Johnson, City Clerk Sam Shoucair 32400 PASEO ADELANTO, SAN JUAN CAPISTRANO, CALIFORNIA 92675 • (714) 493-1171