1997-0903_AYSO REGION 87_Insurance Certificate :::i; . i:::i22 .:.:'': :..:`:i,?i`;i`i;:.:i;E i'a?%:'ii.i;ii;; DATE MM/DD
9/ 3/1997
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 8 517 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
ORGANIZATION COMPANY
12501 SOUTH ISIS AVENUE C
HAWTHORNE, CA. 90250
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 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 TR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
DATE(MM/DD/YY) DATE(MM/DD/YY)
GENEW.1. LIABILITY GENERAL AGGREGATE $2,000,000
A X COMMERCIAL GENERAL LIABILITY 'CKO 1301538 09/01/97 09/01/98 PRODUCTS-COMP/OP AGG s2,000,000
CLAIMS MADE X OCCUR PERSONAL&ADV INJURY $1,000,000
OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $1,000,000
FIRE DAMAGE(Any one fire) $ 100,000
MED EXP(Any one person) $ 5,000
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 $ -1
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
CERTIFICATE HOLDER,' CANCELLATION
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 CAPISTRANO BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
ATTN: KAREN CROCKER OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
32400 PAS EO ADELANTO AUTHORIZED REPRESENTATIVE- r`}
SAN JUAN CAPISTRANO CA 92675 , '' , - C '. S -
IEL : sep u? , ( 25 :1( NO .UU1 V .U4
Prodi . PHONE F-Iuc.:?c+ PU3
S. SCOPE OP COWLftAC,L Tills policy, II primary, &Hord% coverage it least as 5rods !3`.
(1) Insurance Services (Mice form number CL. 0002 (Ed, 1/73), Comprehensive Le►era.
Liability Insurance and Insurance Servicer Of flee form number er1. 0404 3rosd r Jr
comprehensive General Liability endorsement; or
(2) Insurance Services Office Commercial General Liability Coverage, "occur rend"
form CG 0001 or "claims-made" form CC 00021 or
(3) If excess, affords coverage which is et least as broad as the primary insure nre
forms referenced in the preceding sections (1) and (2).
4,
SEVERABILITY QP INTEREST. The insurance if forded by this policy applies separately to
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 01 liability.
1. PROVISIONS REGARDING THE INSURED'S DUTIES AFTER ACCIDENT OR LOSS, skny
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 Ucers,
officials, 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 mall return receipt requested has been given to the City. Such notice
Shall be addressed as shown in the heading of this endorsement.
C. QICIDENT AIV,I CLAS R ORT1NG pgtQCJDURE
Incidents and claims are to be reported to the insurer its
ATMs President
(Title) (Department)
As oci ates
ompany _.w
Po Box 8517
crest rMs
Fort Wayne, IN 46725
h tate e
e421941
�} 219-482-5455
.ter
) D. S . OP '. • •R . /Gk* ' R ' NTATIgSW T1IjSURER
31-1(hI -i ry ' . Di ' er U (prIn type name), weirs that I have authority to bind the below listed
surance company andby my signa2"t�rb corm :a cmyrisly
sicimaitE (orlarestin
signature r, red on endorsement furnished to the City
Ct�,♦IlVI7.�ITICNs Diller & Associates TlTflrt President-------------
VSs PO Box 8517 Tgt.1:Pl t � ) 219-482-5455
Fort Wayne, IN 46725
ILL ; Jep UL, ( 25 ;1( NO .UUL r .UJ
Fr(.4n PHOtZ tic.
. F 1(19...! 19'F7 '_i:58k11 Pi 12
biefLITY ENDORSEMENT
r ' ,
ttTY or 5AN DUAN CAPISTRANO
P�
32400 Peo Addfito
soh
2tan Gplst'asrio,Callfaornla 1203
ATTN:,_ - -
A. M_Lic INFORMATION Endorsement .
1. Insurance Companyrte_(TOT= Policy Number
2. policy Term (From) Endorsement Effective bate __
'"
7, Named Insured
4. Address of 11ame 'nsured r
S, Limit of Liability Any One ccurrence ggregate ""
General Liability Aggregate (check ones)
Applies"per location/project"
is twice the oecurrenCe limit
6. Deductible or Sell-Insured Retention(Nil unless otherwise specitledh $_
7. Coverage is equivalent tot
Comprehensive General Liability form GL0002 (Ed 1/72)
Commercial General Liability "claims-made" form CGO002 f ~'
8. Bodily Injury and Property Damage Coverage Is:
"claims-made"
"occurrence"
li claims-made, the retroactive date Is
-
B. OLICY AMENDMLNTI
This ehdorsement is issued in consideration of the policy premium. Notwithstanding any Inconsistent
statement in the policy to which this endorsement is attached or any other endrrsement attached
thereto, it Is agreed as failowsa
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 iron (a) activities performed by or on behalf of the Named
insured, (b) products and completed operations of the Named Insured, of (c)premises owned.
leased or used by the Named Insured.
R. CONTRIBUTION NOT RLQIJIR!D. 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 an unbroken chain of coverage excess of the Named
Insureds scheduled underlying primary coverage. In either event. any other insurance F
maintained by she City, its elected or appointed officers, officials, employees or volunteers
shall be in excess of this insurance and shall not contribute with it.
(OVER)