1994-1130_EMPIRE PIPE CLEANING & EQUIPMENT_Insurance Certificate AI:/11Z111. C E RTI Fl CA1 OF INSURANCE CSR JS ISSUE DATE(MM/DD/YY)
EMPIR-1 11/30/94
PRODUCER THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND
BOSWELL INSURANCE AGENCY CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE
Agents & Brokers, Inc. DOES NOT AMEND,EXTEND OR f1L tIIM)COVERAGE AFFORDED BY THE
P.O. Box 461,9 POLICIES BELOW.
Mission Viejo CA 92690 COM PptES IAFFORLIIIF40 &IERAGE
Joe A. Boswell
714-855-0430 A Golden Eagle InGehtlt1►l ompany
LETTEFI
p.E.P.A.IIT.N.E NT
COMPANY "'CITY 0.F.,SAN
INSURED LETTER B JUAN CAf iS"TRA4
COMPANY `+ 6;16e0�,,LETTER J
Empire Pipe Cleaning & COMPANY
Equipment, Inc. LETTER
P.O. Box 8035
Anaheim CA 92802 �R 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 UNITS
LTR DATE(MWDD/YY) DATE (MM/DD/YY)
GENERAL LIABILITY GENERAL AGGREGATE $2,000,000
A X COMMERCIALGENERALUABIUTY CCP26524700 04/07/94 04/07/95 PRODUCTS-COMP/OPAGG. S 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 CCP26524700 04/07/94 04/07/95 LIMIT
ALL OWNED AUTOS BODILY INJURY
X SCHEDULED AUTOS (Per person) $
X HIRED AUTOS BODILY INJURY
X NON-OWNED AUTOS (Per accldenl) $
GARAGE LIABILITY
PROPERTY DAMAGE $
EXCESS LIABILITY EACH OCCURRENCE $3,000,000
A UMBRELLA FORM EXC26524800 04/07/94 04/07/95 AGGREGATE $
X OTHER THAN UMBRELLA FORM
A WORKER'S COMPENSATION PWC27409102 11/01/94 11/01/95 X . STATUTORY LIMITS
AND EACH ACCIDENT $ 1,000,000
DISEASE—POLICY UMIT $1,000,000
EMPLOYERS'LIABILITY
DISEASE—EACH EMPLOYEE $1,000,000
OTHER
DESCRIPTION OF OPTRATIONS/LOCATIONSEHICLES SPECIAL ITEMS
Certi i /Vcate issued to update workers ' compensation policy renewal only.
*10 days for non-payment of premium or non-reporting of payroll
CERTIFITE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL
MAIL 3l1 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
City of San Juan Capistrano LEFT, :. e ' .-_ e - - • e e:
• •32400 Paseo Adelanto or ANY KIND UPON TI IC O6MPANY-IT9 AGENTS OfiREPRESENTATIVES.
San Juan Capistrano CA 92675 AUTHORIZED REPRESENTATIVE
•
#
Joe A. Boswell
Ci AC RD CORR4.RAT ON:'1.
AP
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October 27, 1994
Empire Pipe Cleaning & Equipment Inc.
P.O. Box 8035
Anaheim, California 92802
Re: Renewal of Workers' Compensation Certificate of Insurance (City Sanitary Sewer Line
Maintenance)
Dear Gentlemen:
The Workers' Compensation Certificate of Insurance, regarding the above-referenced service, is due
to expire on November 1, 1994. In4.ccordance 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 the November 1, 1994, expiration date.
If you have any questions, please contact me at (714) 443-6310.
Thank you for your cooperation.
Very truly yours,
Dawn M. Schanderl
Deputy City Clerk
cc: Cheryl Johnson, City Clerk
Nancy Barney, Public Land & Facilities