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