1995-0414_EMPIRE PIPE CLEANING & EQUIPMENT_Insurance Certificate A/:l/11;11® CERTIFIC. 'E OF INSURANCE CSR JS tsslIN:IJA'04/14/95
EMPIR-1
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
gtorrt INSURANCE AGENCY CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE
Agents &Brokers, Inc. DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
P.O:,Box 4648 POLICIES BELOW.
Mistion Viejo CA 92690
COMPANIES AFFORDING COVERAGE
Joe A. Boswell
.. . ... .. ..
714-855-0430 COMPANY L.' CNA Insurance Companies
IE7TER
COMPANY B Golden Eagle Insurance Company
INSURED
COMPANY C
LETTER
Empire Pipe Cleaning & COMPANY D
Equipment, Inc. LEITER
P.O. Box 8035
Anaheim CA 92812 COMPANY LETTER E
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 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 1034438390 04/07/95 04/07/96 .PRODUCTS-COMP/OPAGG. $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) $ 50,000
MED.EXPENSE(Any one person) $ 5,000
AUTOMOBILE LIABILITY
COMBINED SINGLE $ 1_000,000
A ANY AUTO 1034439717 04/07/95 04/07/96 LIMIT
ALL OWNED AUTOS
BODILY INJURY $
X SCHEDULED AUTOS (Per person)
X HIRED AUTOS BODILY INJURY
X NON-OWNED AUTOS (Per accident) $
GARAGE LIABILITY
PROPERTY DAMAGE $
EXCESS LIABILITY :EACH OCCURRENCE $ 3,000,000
A X UMBRELLA FORM 1034439734 04/07/95 04/07/96 AGGREGATE $ 3,000,000
OTHER THAN UMBRELLA FORM
B WORKER'S COMPENSATION PWC27409102 11/01/94 11/01/95 X STATUTORY LIMITS
EACH ACCIDENT $ 1,000,000
AND DISEASE—POLICY LIMIT $ 1,000,000
EMPLOYERS'LIABILITY
DISEASE—EACH EMPLOYEE .U.„000,000
OTHER
'.,L -.i i TI
ri
SCR ON OF O E TIO /LOCATIQ S HI LES/ ECTAL I E S J;
y an ommum y/` eaeveio nt Agency, itselected orappointed ,, -;
inturers, otfiorm�s, eemD oyeestandedolunteers are included as adiiona
P
*1Q gays for non-oavment of premium or non-reporting, Qf_pavrQ1l 77
CERTIFICATE HOLDER CANCELLATION c,.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCFT.I.FD BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL
MAIL*30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
City of San Juan Capistrano
Conminity Redevelopment Agency
32400 Paseo Adel auto "'"' ' ' ' ' ' ' - ' • "'
San Juan Capistrano CA 92675 AUTHORIZED REPRESENTATIVE
Joe A. BoswelT App, i, vz-e-.e
ACE) $:5,5(7f90) • ACD CORPORATION 1990
'4s
c o
•
'k4rJ f '1'.
• �jr 9 11-rt .Yc..r',
C./1%A
For All the Commitments You Make
•
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 additional
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 additional
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. The limits of insurance applicable to the additional insured are those specified in the written contract or agreement
or in the Declarations for this policy whichever are less. These limits of insurance are inclusive of and not in
addition to the limits of insurance shown in the Declarations.
The insurance provided to the additional insured does not apply to "bodily injury", "property damage", "personal injury".
or "advertising injury" arising out of an architect's, engineer's, or surveyor's rendering of or failure to render any
professional services including:
1. The preparing, approving, or failing to prepare or approve maps, drawings, opinions, reports, surveys, change
orders, design 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 YOUR
POLICY UNLESS ANOTHER EFFECTIVE DATE IS SHOWN BELOW.
POLICY tHANGNO. 103+438390 EFFECTIVE DATE OF THIS POLICY CHANGE
EMPIRE PIPE CLEANING & EQUIPMENT, INC. 4-7-95
COUNTERSIGNED DATE AUTHORIZE REPRESENTATIVE
f///
JOE A. QSWELL/j s
G-17957-B
(ED. 09/92)
�M'0II
h
v-r
t ,• I V0 I, MEMBERS OF THE CITY COUNCIL
6j COLLENE CAMPBELL
• USE - >!!! WYATT HART
DRUG2'� h ., m(oeroeaifu GIL JONES
IS • (siatos (0 1961 CAROLYN NASH
X11 1776 i IDAVID SWERDLIN
• • CITY MANAGER
March 23, 1995 • •--1400
GEORGE SCARBOROUGH
Empire Pipe Cleaning &
Equipment, Inc.
P.O. Box 8035
Anaheim, CA 92802
Re: Renewal of General Liability and Automobile Liability Certificates of Insurance (City
Sanitary Sewer Line Maintenance)
Gentlemen:
The General Liability and Automobile Liability Certificates of Insurance, regarding the above-
referenced service, are due to expire on April 7, 1995. In accordance with your agreement, the
insurance certificates need to be renewed for an additional period of one year. The agreement
requires a general liability endorsement form naming the City of San Juan Capistrano as an additional
insured. I have included a City approved endorsement form to submit to your insurance company;
however, your insurance company may provide their own endorsement form.
Please forward the updated certificates and the endorsement form to the City, attention City Clerk's
office, by April 7, 1995.
If you have any questions, please contact me at (714) 443-6310.
Thank you for your cooperation.
Very truly yours,
katA.,660./Lciap
Dawn M. Schanderl
Deputy City Clerk
Enclosure
cc: Cheryl Johnson, City Clerk
Nancy Barney, Administrative Assistant
32400 PASEO ADELANTO, SAN JUAN CAPISTRANO, CALIFORNIA 92675 • (714) 493-1171