1997-0310_BOTACO INC._Inurance Certificate A1:111:11® CERTIFICA OF INSURANCE CSR JS DATE(MM/DD/VY)
BOTAC-1 03/10/97
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
BOSWELL INS AGENCY (#0A96080) ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Agents & Brokers, Inc. ! HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P.O. Box 4648 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Mission Viejg CA 92690 COMPANIES AFFORDING COVERAGE
Joe A. Boswell COMPANY
PnoneNo. 714-855-0430 Fax A Golden Eagle Insurance Company
INSURED COMPANY
B CNA Insurance Companies
COMPANY
BotaCo Inc. C Mercury Casualty Company
31921 Camino Capistrano, #401 COMPANY
San Juan Capistrano CA 92675 D
COVERAGES
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.
I f
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR DATE(MM/DD/YY) DATE(MM/DD/YY)
GENERAL LIABILITY GENERAL AGGREGATE $ 2,000,000
B X COMMERCIAL GENERAL LIABILITY 134883700 05/01/96 05/01/97 PRODUCTS-COMP/OPAGG $ 1,000,000
CLAIMS MADE X OCCUR PERSONAL&ADV INJURY $ 1,000,000
X OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ 1,000,000
FIRE DAMAGE(Any one fire) $ 50,000
- I
MED EXP(Any one person) $ 5, 000
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 600, 000
C ANY AUTO AC11017268 j 05/25/96 05/25/97
ALL OWNED AUTOS
BODILY INJURY
X SCHEDULED AUTOS (Per person)
X HIRED AUTOS
BODILY INJURY $
X NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO i OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EXCESS LIABILITY EACH OCCURRENCE $ 2,000,000
B X UMBRELLA FORM 134883714 05/01/96 05/01/97 AGGREGATE $
OTHER THAN UMBRELLA FORM $
A WORKERS COMPENSATION AND X STATUTORY LIMITS
EMPLOYERS'LIABILITY SS��
EACH ACCIDENT �i 1,000,000
THE PROPRIETOR/ INCL NWC29572102 01/01/97 01/01/98 DISEASE-POQCYLIMIT -$-1,000,000
PARTNERS/EXECUTIVE
OFFICERS ARE: X j EXCL DISEASE•EASH-EMPLOYEE $ 1,Qgi0,000
OTHER -< � C,
hl-
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
The City & the Community Redevelopment Agency, its elected or appointed c
officers, officials, employees and volunteers are included as additional
insuredser form G-17957-B attached.
*10 days for non-payment of premi or non-reporting of payroll
**Replaces certificate issued 1/2/97** xxx
CERTIFICATE HOLDER CANCELLATION
SANJU9 9 I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL MAIL
City of San Juan Capistrano *30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Attn: City Clerk
-BUT-FAILURE TUMflfL CUCIf NOTI6E-SHAtL-iMPOSE-NO-01
32400 Paseo Adelanto
San Juan Capistrano CA 92675 OF ANY KIND-HP9fil-THE-00MP4NV,FTS-AGENTS-OR REPRE&ENTA-WAS
AUTHORIZED REPRESENTATIVE >'1/76(1
Joe A. Boswell 'tet
ACORD 25-S13/93) ACORD'CORPORATION 1993
CNA
For A17 Ow Commltmcn.You lisle' •
• THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET ADDITIONAL INSURED ENDORSEMENT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
WHO IS AN INSURED (Section Ii) is amended to include as an insured any person or organization (called addition
insured) whom you are required to add as an additional insured on this policy under:
1. A written contract or agreement; or •
2. An oral agreement or contract where a certificate of insurance showing that person or organization as an additionz
insured has been issued; but:
the written or oral contract or agreement must be:
(a) currently in effect or becoming effective during the term of this policy; and
(b) executed prior to the "bodily injury," "property damage," "personal injury," or "advertising injury."
The insurance provided to the additional insured is limited as follows:
1. That person or organization is only an additional insured with respect to liability arising out of
a. Premises you own, rent, lease, or occupy or • •
b. "Your work" for that additional insured by or for you.
•
2. Tne limits of insurance applicable to the additional insured are those specified in the written contract or agreemen
or in the Declarations for this policy whichever are less. These limits of insurance are inclusive of and not it
addition to the limits of insurance shown in the Declarations.
Tne insurance provided to the additional insured does not apply to "bodily injury", "property damace", "personal injury'
or "advertising injury" arising out of an architect's, encineer's, or surveyor's rendering of or failure to render an}
professional services including:
1. Tne preparing, approving, or failing to prepare or approve maps, drawincs, opinions, reports, surveys, chance
orders, desicn or specifications; and
2. Supervisory, inspection, or engineering services.
•
Any coverage provided hereunder shall be excess over any other valid and collectible insurance available to the
additional insured whether primary, excess, contingent or on any other basis unless a contract specifically requires that
this insurance be primary or you request that it apply on a primary basis.
THiS ENDORSEMENT IS A PART OF YOUR POLICY AND TAKES EFFECT ON THE EFFECTIVE DATE OF YOUF
POLICY UNLESS ANOTHER EFFECTIVE DATE IS SHOWN EE?OW.
POLICY E NO. 134883700 EFFECTIVE DATE OF THIS POLICY CHANGE
B TACO, INC. 5-1-96
COUNTERSIGNED DATE AUTHORIZED REPRESENTATIVE
•
JOE A. BOSWELL/JS
G-17957-B
(ED. 09/92)
ilk. Mercury libualty Company11116
Li NOTICE OF TERMINATION OF LOSS PAYEE'S INTEREST
!!! NOTICE OF TERMINATION OF ADDITIONAL INSURED'S INTEREST
Form 3817
Post Office Department AFFIX
Received from: STAMP AND
MERCURY CASUALTY COMPANY This is notice that your interest
POSTMARK in this policy has been terminated.
One piece of ordinary mail addressed
Loss To LAD/ OF SAS .ItlAt+t CAPISTli, '. AUTOMOBILE: SCHEDULE
Payee ATTN. CITY CLEM NON-OWNED
32400 PASEO ADELANTO INSURED: isOTACO, I)C.
SRN JUAN CAPISTRANO, CA 92675
POLICY NO.: AC 11017268
THIS RECEIPT DOES NOT PROVIDE FOR INDEMNIFICATION
POSTMASTER DATE OF NOTICE: V6/9/
BOSWEI,L INS. AGENCY 444
Agent . /I ..
VaLkt
Form T:1
C, I.7 -4 73
Post Office Department AFFIX h
r C) CI
N rn
Received from: STAMP AND
ern
MERCURY CASUALTY COMPANY ��v a w v
POSTMARK —0
One piece of ordinary mail addressed =, +
--3
Additional To
Interest
P.• E i D E N T
THIS RECEIPT DOES NOT PROVIDE FOR INDEMNIFICATION
POSTMASTER
U-9 12190
I IPKI I-InI npRC/AnnITlnMAI IMM I IRPf'c r-npv