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1997-0930_DBX_Insurance Certificate \II'��II� ��ww�. 11IC " DATE(MM/DDIYY) ?; 9/30/97 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION C a l c o I n s Brokers & Agents n t s ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 9 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1450 r a z e e Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P .O. Box 85371 COMPANIES AFFORDING COVERAGE San Diego , CA 92186-5371 COMPANY 619-260-3846 A INSURED COMPANY DBX , Inc . B American Automobile Ins . Co . 42066 Avenida Alvarado , Ste . C COMPANY Temecula , CA 92590 C HIH America COMPANY D :.SERA THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDINGANYREQUIREMENT,TERMOR CONDITION OFANYCONTRACTOROTHERDOCUMENTWITHRESPECT TO WHICHTHIS 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 LTR DATE(MMIDDIYY) DATE(MMIDDIYY) GENERAL LIABILITY GENERAL AGGREGATE $ 2000000 B X COMMERCIAL GENERAL LIABILITY MZG80666275 3/24/97 3/24/98 PRODUCTS-COMP/OP AGG $ 2000000 CLAIMS MADE X OCCUR PERSONAL & ADV INJURY $ 1000000 OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ 1000000 FIRE DAMAGE(Any one fire) $ 50000 MED EXP (Any one person) $ 5000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ g X ANY AUTO MZG80666275 3/24/97 3/24/98 1000000 ALL OWNED AUTOS BODILY INJURY $ 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 OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM $ WORKERS COMPENSATION AND X STATUTORY LIMITS EMPLOYERS'LIABILITY C C000697301 10/01 /97 10/01 /98 EACH ACCIDENT $ 1000000 THE PROPRIETOR/ INCL DISEASE •POLICY LIMIT $ PARTNERS/EXECUTIVE 1000000 OFFICERS ARE: EXCL DISEASE•EACH EMPLOYEE $ 1000000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS Re : Camino Capistrano and Avenida Padre Traffic Signal . Certificate holder is named as primary additional insured per CG2010 attached . 30 days cancellation notice except 10 days for non payment of premium. ATE H , • SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ARDfAVAXI'XMAIL City of San Juan Capistrano 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Attn : Alan Oswald XR' >fVIPR9000(3u3FkSA9€Xs1104E;11PR ncticx0A)PSVX,K1NX 4t1 OTO( 32400 Paseo Ade I anto XIS %SA*VinilDXritiV0iPTEX 64g04,6 Xii(405k6 MI(Xalk X iiliMfe4404V:XXX San Juan Capistrano , CA 92675 AUTHORIZ REPRESENTATIVE 053094000 x AC�Rtk':2;;::*S;r,:;::9 ..' >'': >':> ; <>> >> `«'<>>f<'<'�'>< z<z�<:i!i i' j>y<> <<;2<< <«< < >;<:'yy::::;::>:::>::>::::>:: :::::::> >:'> 'iB©:4 k..:a:.;:.;:>:;:>::;:O.;:.::,`::j.fi>:.:TIO::r}{;:.:;:;:::<., �� 5 S�31'9�)........ .:::.�AGC).� phF3Ri)f�71Qt!�:.1.99�. • • • Additional Insured - Owners, Lessees or Contractors (Form B) • CG 20 10 11-85 Policy Amendment General Liability INSURED: POLICY NUMBER: DBX, INC. MZG80666275 PRODUCER: CALCO INS BROKERS &AGENTS EFFECTIVE DATE: 3/24/97 SCHEDULE Name Of Person Or Organization: CITY OF SAN JUAN CAPISTRANO, ITS ELECTED OR APPOINTED OFFICERS, OFFICIALS, EMPLOYEES & VOLUNTEERS 32400 PASEO ADELANTO SAN JUAN CAPISTRANO, CA 92675 (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 in- - liability arising out of your work for that insured by clude as an insured the person or organization or for you. shown in the Schedule, but only with respect to • PRIMARY INSURANCE ENDORSEMENT It is agreed that such insurance is afforded by this policy for the benefit of shall be priman,POTKpects any claim, loss or liability wising out of the subcontractor's operations or by its independent contractors and any other insurance maintained by the above referenced additional insureds shall be non-contributory with the insurance provided hereunder. Except with respect to the limits of insurance, this insurance applies as if each named insured were the only named insured and separately to each insured against whom claim is made or suit is brought. Job: CAMINO CAPISTRANO AND AVENIDA PADRE TRAFFIC SIGNAL. This Form must De attached to Change Enaorsement when issued arer me Policy 1s written. ONE OF THE FIREMAN'S FUND INSURANCE COMPANIES AS NAMED IN THE POLICY Presioent CG3IO :1.35 CJnl�ins CczyrfgfIfec M3Ier131 of InsurJnCe Serv,ces Office Inc 1994 Juan '• • DRUG USE C� E v- i; MEMBERS OF THE CITY COUNCIL is I[1� COLLENE CAMPBELL JOHN GREINER 1s COAPOxxTED WYATT HART utenisxtD 1961 GIL JONES 1776 'A1 M.SWERDLIN • _I • CITY MANAGER GEORGE SCARBOROUGH September 9, 1997 DBX, Inc. 42066 Avenida Alvarado, Suite C Temecula, California 92590 Re: Renewal of Workers Compensation Certificate of Insurance (Camino Capistrano and Avenida Padre Traffic Signal) Gentlemen: The Workers' Compensation Certificate of Insurance,regarding the above-referenced project, is due to expire on October 1, 1997. In accordance with your agreement, the insurance certificate needs to be renewed for an additional period of one year. Please forward an updated certificate to the City of San Juan Capistrano, attention City Clerk's office, by October 10, 1997. If you have any questions, please contact me at(714) 443-6310. Thank you for your cooperation. Very truly yours, AUWAVVel4deke, Dawn M. Schanderl Deputy City Clerk cc: Cheryl Johnson, City Clerk Alan Oswald, Traffic Engineer 32400 PASEO ADELANTO, SAN JUAN CAPISTRANO, CALIFORNIA 92675 • (714) 493-1171