1996-1031_EMPIRE PIPE CLEANING & EQUIPMENT_Insurance Certificate . A4.4101,111. CERTIFICi E OF INSURANCE CSS
DATE(MM/DD/YY)
1D/31/96
PRODUCER THIS CERTIFICATE is IssUED AS A MATTER OF INFORMATION
Crosby Insurance Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P.O. BOX 5017 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
60 E. Ninth St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Upland CA 91785-5017 COMPANIES AFFORDING COVERAGE
COMPANY
909-985-0345 A VALLEY FORGE INSURANCE CO.
INSURED
COMPANY
B AMERICAN CASUALTY COMPANY
EMPIRE PIPE CLEANING & COMPANY
EQUIPMENT, INC. C CONTINENTAL CASUALTY CO.
P.O. BOX 8035 COMPANY
ANAHEIM CA 92812 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.
CO I 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
A X COMMERCIAL GENERAL LIABILITY 1055583004 04/07/96 04/07/97 PRODUCTS-COMP/OP AGG $ 2,000,000 _
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) $ 200,000
I MED EXP(Any one person) $ 50,000
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $ 1,000,000
A X ANY AUTO 1055583018 04/07/96 04/07/97 _
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 $3,000,000
B X UMBRELLA FORM 1055583021 04/07/96 04/07/97 AGGREGATE $3,000,000
OTHER THAN UMBRELLA FORM $
C WORKERS COMPENSATION AND X STATUTORY LIMITS
EMPLOYERS'LIABILITY EACH ACCIDENT $ 1,000,000
THE PROPRIETOR/ X INCL 1062658603 11/01/96 11/01/97 DISEASE-POLICY LIMIT $ 1,000,000
PARTNERS/EXECUTIVE -
OFFICERS ARE: EXCL DISEASE-EACH EMPLOYEE $ 1,000,000
OTHER
A PERSONAL PROPERTY 1055583004 04/07/96 04/07/97 $51,500.
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
Re: All Jobs performed by the Named Insured. (X)
(Special Form)
*10 Days Notice of Cancellation will be given for non-payment of premium.
CERTIFICATE HOLDER CANCELLATION
SANJUAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL nrmu.i on TO MAIL
*30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
City of San Juan Capistrano •
� •'
32400 Paseo Adelanto •
San Juan Capistrano CA 92675 AUTHORIZED REPRESENTA •,E
-1.5rJre
ACORD 25-S(3/93) CORD,CORPORATION 1993
(CERTLTR. KO)
CROSBY INSURANCE , I N C .
P.O. BOX 5017
UPLAND, CALIFORNIA 91785-5017
PHONE: (909) 985-0345
FAX: (909) 981-9385
November 1, 1996
ATTN: CERTIFICATE HOLDER
RE : W. C . RENEWAL CERTIFICATE FOR
EMPIRE PIPE CLEANING
& EQUIPMENT, INC.
RENEWAL EFFECTIVE 11/01/96 TO 11/01/97
THE ATTACHED CERTIFICATE OF INSURANCE IS FOR THE WORKER' S
COMPENSATION RENEWAL EFFECTIVE 11-01-96 ONLY. THE PREVIOUS
CERTIFICATE AND ADDITIONAL INSURED ENDORSEMENT, IF APPLICABLE,
ISSUED FOR YOUR COMPANY IS STILL VALID FOR THE OTHER COVERAGES .
PLEASE UPDATE YOUR RECORDS AND ADD THIS CERTIFICATE TO YOUR
FILE . PLEASE GIVE ME A CALL IF YOU HAVE ANY QUESTIONS REGARDING
THIS . THANK YOU.
SINCERELY,
COMMERCIAL DEPT .
CROSBY INSURANCE, INC.
ENCL :
LIABILITY ENDORSEMENT
CITY OF SAN JUAN CAPISTRANO
COMMUNITY REDEVELOPMENT AGENCY
32400 Paseo Adelanto
San Juan Capistrano,California 92675
ATTN:
A. POLICY INFORMATION Endorsement# 1
1. Insurance Company Valley Foreg Insurance Company (CNA) ;Policy Number 1055583004
2. Policy Term(From) n 4/n 7/4h (To) 04 07/97 ;Endorsement Effective Date 04/07/96
3. Named Insured Empire Pipe Cleaning Equipment.
4. Address of Named Insured P. 0. Box 8035, Anaheim, CA 92812
5. Limit of Liability Any One Occurrence/Aggregate$ 2,000,000 / 2,000,000
General Liability Aggregate(Check one:)
Applies"per location/project" X
Is twice the occurrence limit
6. Deductible or Self-Insured Retention(Nil unless otherwise specified): $
7. Coverage is equivalent to:
Comprehensive General Liability form GL0002(Ed 1/73) Form CG0001 (11/85)
Commercial General Liability"claims-made"form CG0002
8. Bodily Injury and Property Damage Coverage is:
"claims-made"
X "occurrence"
If claims-made,the retroactive date is
B. POLICY AMENDMENTS
This endorsement is issued in consideration of the policy premium. Notwithstanding any inconsistent statement in the policy to which this
endorsement is attached or any other endorsement attached thereto,it is agreed as follows:
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 from;(a)activities performed
by or on behalf of the Named Insured,(b)projects and completed operations of the Named Insured,or(c)premises owned,
leased or used by the Named Insured. *Additional
2. CONTRIBUTION NOT REQUIRED. As respects: (a)work performed by the Named Insured for or on behalf of the
City-,or(b)projects 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 Insured's scheduled underlying
primary coverage. In either event, any other insurance maintained by the City,its elected or appointed officers,officials,
employees or volunteers shall be in excess of this insurance and shall not contribute with it.
3. SCOPE OF COVERAGE. This policy,if primary,affords coverage at least as broad as:
(I) Insurance Services Office form number GL0002 (Ed. 1/73), Comprehensive General Liability Insurance and
Insurance Services Office form number GL0404 Broad Form Comprehensive General Liability endorsement;or,
* (2) Insurance Services Office Commercial General Liability Coverage, "occurrence" form CG0001 F77'
(3) If excess,affords coverage which is at least as broad as the primary u,.uiance forms referenced in the preceding'
sections(1)and(2).
4. SEVERABILITY OF INTEREST. The insurance afforded by this policy applies separately to each insured who is seeking
coverage or against whom a claim is made or a suit is brought,except with respect to the Company's limit of liability.
5. PROVISIONS REGARDING THE INSURED'S DUTIES AFTER ACCIDENT OR LOSS. Any 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 officers,officials,employees or volunteers.
6. CANCELLATION NOTICE. The insurance afforded by this policy shall not be suspended,voided,cancelled,reduced
in coverage or 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. INCIDENT AND CLAIM REPORTING PROCEDURE
Incidents and claims are to be reported to the insurer at:
AT.FN: Karen Ord, Commercial Department
(Title) (Department)
Crosby Insurance Inc.
(Company)
60 East 9th Street
(Street Address)
Upland, California 91785-5017
(City) (State) (Zip code)
909-985-0345
(Telephone)
D. SIGNATURE OF INSURER OR AUTHORIZED REPRESENTATIVE OF THE INSURER
Karen O r d (print/type name),warrant that I have authority to bind the below listed insurance
company and by my signature hereon do so bind this company.
SIGNATURE OF AUTHORIZED REPRESENTATIVE
(Original signature required on endorsement furnished to the City)
ORGANIZATION: Crosby Insurance, Inc. TITLE Commercial Service Representative
ADDRESS: 60 E. 9th Street, Upland, CA 91785-5017 TELEPHONE: 909-985-0345