1997-0929_AYSO REGION 87_Insurance Certificate ;;;;;., DATE(MMIDDIYY)
A4:111:11® CERTIFICATW OF INSURAI . .. • 9/29/1997_'
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Diller & Associates HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P.O. Box 8517 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Ft. Wayne, IN 46808 COMPANIES AFFORDING COVERAGE
(219) 482-5455 COMPANY
A ST. PAUL FIRE & MARINE INS . CO
INSURED COMPANY
AMERICAN YOUTH SOCCER B
ORGANI ZAT ION COMPANY
12501 SOUTH ISIS AVENUE C
HAWTHORNE, CA. 90250
COMPANY
D
tti1iERAGE$
THIS IS TO CERTIFY THAT I.if POLICIES OF INSURANCE LISILD BLLOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE_- i OR 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 TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTRDATE(MM/DD/YY) DATE(MM/DD/YY)
GENERAL LIABILITY GENERAL AGGREGATE $2,000,000
A COMMERCIAL GENERAL LIABILITY CKO 1301538 09/01/97 09/01/98 PRODUCTS-COMP/OP AGG _ $2,000,000
CLAIMS MADE X OCCUR PERSONAL 8 ADV INJURY $1,000,000
OWNER'S 8 CONTRACTOR'S PROT EACH OCCURRENCE $1,000,000
FIRE DAMAGE(Any one fire) $ 100,000
MED EXP(Any one person) $ 5,000
AUTOMOBILE LIABILITY
ANY AUTO COMBINED SINGLE LIMIT $
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
EMPLOYERS' LIABILITY
- EACH ACCIDENT $
THE PROPRIETOR/ INCL DISEASE-POLICY LIMIT $
PARTNERS/EXECUTIVE -
OFFICERS ARE: EXCL DISEASE-EACH EMPLOYEE $
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
CERTFICATE HOLDER IS AN ADDITIONAL INSURED BUT ONLY WITH RESPECT TO
AYSO ACTIVITIES .
REGION: 87
;;':<::CA1sIG�£LAT1a3N
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
3 0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
CITY OF SAN JUAN CAPITRANO BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
ATT KAREN CRACKER OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
32400 PAS EO A DE CENTO AUTHORIZED REPRESENTTAi1VE
N
SAN JUAN CAP ISTRAO CA 92675 // � PC U
A0.00025-5 (3/93)
U
Utz ; yep ws,Jr 1Z Z1 ivo .uuu r .up
_From : , PHONE No. :
r •
1 . 199 9•: )ti
WeViciriTY CNINDRSEMENT
CITY OF SAN 3UI►N CAPISTRANO
12400 Paseo Adelant4
San Juan C.apburro.ChM tomla '2673
ATTNt
A. 0.1LCY INFORMATION Endorsement 1/
ST. PAUL FIRE & MARINE
1. insurance Company INS. CO. Policy Number__CIO 1301.538`_ , . _.,,_•._
2. Policy Term (From) o 138 AjEndorsement Effective—Date w�,,�,,,_••
3. Named insured e u • II •
4. Address of Named nsured I eiyif: 62ser
te
Limit of Liability Any One •ccurrence ggrega
General Liability Aggregate(check one;)
Applies"per location/project" _
is twice the occurrence limit
6. Deductible or Self-Insured Retention(N11 unless other wise specified): $
7. Coverage is equivalent tot
Comprehensive General Liability form GL0002 (Ed 1/73)
Commercial General Liability"claims-made" form CG0002
S. Bodily injury and Property Damage Coverage Ist
"claims-mads"
1 J 0n,000 "occurrence"
If claims-made, the retroactive date is.
-
D. PORGY AMENDMENTS
This endorsement is issued in consideration of the policy premium. • • ' ' • • _•XXXX
owst which this endorsement is attached or any other endorsement attar e
Thereto, itxis iareed�
go
1. INSURED. The City and the Community Redevelopment Agency, Its elected or appointed
officers, officials, employees and volunteers are included as insureds with regard to damages
and defense of claims arising fromt (a) activities performed by or on behalf of the \smed
V.p.)
insured, (b) products and completed operations of the Named insured, or (c)premises owned,
��L' leased or used by thedisiy�i�dr ADDITIONAL PERSON.
Pia UNDERWRITER
2. CONTRIBUTION NOT REQUIRED. As respects: (a) work performed by the Named Insured
for or on behalf of the City; or (b) products sold by the Named Insured to the City; or (c)
premises leased by the Named Insured from the City, the insurance afforded by this policy
shall be primary insurance as respects the City, its elected or appointed officers, officials,
employees or volunteers; or stand in en unbroken chain of coverage excess of the Named
Insureds scheduled underlying primary coverage. In either event, any other insucam!
maintained by the City, Its elected or appointed offl ers, officials, employees or volunteers
shall'a• in excess of this insurance and shall not contribute with it.
(OVER)
ItL : sep U8 ,9( 12 :20 NO .OUB P .04
• F r c•rn . F1-101,E 1 k.. . Fug , 1'_+'3 a
S. SCOPE OR COVERAGE. This policy, II primary, &fiords caveeaft 1t lent at Sroiti it!
(1) Insurance Services Office form number CL 0002 (Ed. t/73), Comprehensive :.ere,i,
Liability Insurance and insurance Services office !am number CL 0404 'rood F --
comprehensive General Liability endorsement; or
(2) Insurance Services Office Commercial General Liability Coverage, "occurreoe
form CG 0001 or "Claims-made" form CC 00021 or
(3) If excess, affords coverage which is at least as broad as the primary insurance
forms referenced In the preceding sections (1) and (2).
S, SEVERABILITY O1' INTEREST. The Insurance at forded by this policy applies. separately t,s
each insured who Is seekingcoverage or against whom a claim Is made or a suit it Brought.
except with respect to the ompany's limit of liability.
S. PROVISIONS REGARDING THE INSURED'S DUTIES AFTER ACCIDENT OR LOSS. 4n),
failure to comply with reporting provisions of the policy shall not affect coverage provided
to the City and the Community Redevelopment Agency, its elected or appointed of licerl,
of ficials, employees or volunteers.
6. CANCELLATION NOTICE. The insurance afforded by this policy shall not be suspended,
voided, cancelled, reduced In coverage or In limits except after thirty (30) days` prior written
notice by certified mail return receipt requested has been given to the City. Such notice
shall be addressed as shown in the heading of this endorsement.
C, E. .Pi L JU REPORT 49f Ott .
Incidents and claims ire to be reported to the insurer at:
ATTTk CLAIMS DEPT.
(Title) apartment
•e r ens us.- k CO.
ompany
(s trost6Address)
INDIANA OLIS 4 2
(City) tate pCode)
1-800-"752-5844
•
O. SINATURE OP INSU R OR AUTNO,tt1ZED RePRli5ENTAT7yp OF THE INSURER
I, TERRY R. DILLER CPCU (print/type name), warrant that I have authority to bind the below listed
insurance company and by my signature eon do so bind this company.
F (-)
S! NATURE OFA RIPRESENTATIVE (original
signature required on endorsement furnished to the City)
C C NtzATIaN: DILLER AND ASSOCIATES Tl1LEt
SSS: 26-26 SCOTSWOLDE DRIVE T7wifirTE: a�219) 482-5455
FORT WAYNE, IN 46808
I II i