1996-0405_EMPIRE PIPE CLEANING & EQUIPMENT_Insurance Certificate I A/DOrn)® CERTIFIc E OF INSURANCE CSR KO DATE(MM/DD/YY)
EMPIREP 04/05/96
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
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 TYPE OF INSURANCE POLICY NUMBER I 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
MED EXP(Any one person) $50,000
AUTOMOBILE LIABILITY
A X ANY AUTO 1055583018 04/07/96 04/07/97 COMBINED SINGLE LIMIT $ 1,000,000
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 $
WORKERS COMPENSATION AND STATUTORY LIMITS
EMPLOYERS'LIABILITY
EACH ACCIDENT $
THE PROPRIETOR/
INCL DISEASE-POLICY LIMIT $
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL DISEASE-EACH EMPLOYEE $
OTHER
A PERSONAL PROPERTY 1055583004 04/07/96 04/07/97 $51,500.
'•v
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
Re: All Jobs performed by the Named Insured. (X) 1..
(Special Form) =-'-12La> 7,
~ r + rn
*10 Days Notice of Cancellation will be given for non-payment of premium. • '• rn
CERTIFICATE HOLDER CANCELLATION
SANJUAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELbER,BEFRE THE
EXPIRATION DATE THEREOF,THE ISSUING COMPANY WIL MAIL
*30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDERtA[ED TO THE LEFT,
City of San Juan Capistrano
32400 Paseo Adelanto + '
San Juan Capistrano CA 92675 AUT , IZEi�RES TIVE
ACORD 25-S(3/93) ACORD CORPORATION 1993