1994-0406_EMPIRE PIPE CLEANING & EQUIPMENT_Insurance Certificate •
AC;1�ItII. : 04//06/06/CERTIFICA' OF INSURANCE CSR JS ISSUE DATE( YY)
EMPIR-1 94
PRODUCER THIS CERTIFICATE IS ISSUED AS A 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 ALTER THE COVERAGE AFFORDED BY THE
P.O. Box 4648 POLICIES BELOW.
Mission Jiejo CA 92690
COMPANIES AFFORDING COVERAGE ,
Joe A. Boswell
714-855-0430 L�ErMrerNY A Golden Eagle Insurance Company;.= —
COMPANY B C)
-• �C C)
INSURED LETTER
'_
COMPANY T-77-;rT? a- I-n
LETTER :
Empire Pipe Cleaning & COMPANY D
Equipment, Inc. LETTER r ."
P.O. Box 8035
Anaheim CA 92802 COMPANY
ER Y 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 CCP22048001 04/07/94 04/07/95 PRODUCTS-COMP/OPAGG. $ 2,000,000
CLAIMS MADE X OCCUR. PERSONAL&ADV.INJURY $1,000,000
X OWNER'S&CONTRACTORS 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 CCP22048001 04/07/94 04/07/95 OMIT
ALL OWNED AUTOS
BODILY INJURY
X SCHEDULED AUTOS (Per person)
X HIRED AUTOS BODILY INJURY
l( NON-OWNED AUTOS (Per accident) $
GARAGE LIABILITY
PROPERTY DAMAGE $
EXCESS LIABILITY EACH OCCURRENCE $3,000,000
A UMBRELLA FORM CCP2204801 04/07/94 04/07/95 AGGREGATE $
X OTHER THAN UMBRELLA FORM
WORKER'S COMPENSATION STATUTORY UMITS
EACH ACCIDENT $
AND
DISEASE—POUCYLIMIT $
EMPLOYERS'LIABILITY
DISEASE—EACH EMPLOYEE $
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
The City & the Community Redevelopment Agency, its elected or appointed
officers, officials, employees and volunteers are included as additional
insureds per the attached special form required by the City.
*10 days for non-payment of premium
CERTIFICATE HOLDER CICi.IAT#F'1N
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 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 LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
Community Redevelopment Agency
32400 Paseo Adelanto ttntLITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES.
San Juan Capistrano CA 92675 AUTHORIZED REPRESENTATIVE
Joe A. Boswell
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f 1. r 1 • is: . Pi.e Cl .a.. &• E•ui.rnent nc. l �'
•r4. Address of Name. r�sured• P.O. Box• a• , Ana ea :.r ' ., .i 1 . ,..,; 1,.1
ti 1 i r : . . ' 3, . Limit of.Liability Any One octet re g eg�tt ,•e.•e ' , 1i..; � i
i, f•ill.:',' i General Liability Aggregete.:tchccic onet)• . . . . .• .. . i II:•
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1'1,'1:• 1•.• 1• _ •,. �'.�i:.
il: 1' • '6. ::.: Deductible or Sell-Insured Retention(Nil unless. otherwise , e c)t: • ' r5 ;tr:.;
7, Covet" ;ge Is equivalent toa • • • ;• . .. •. .►'.1 ;!•;'• . i•
•p. ; i • . Comprehensive'Cerrerat Liability form ci,,OOOZ (E 1/23 : . . .:xi :, ;, ; 1
I• ' , Commercial Gansu ..Liability 'cc1a rms-'m ide't.ior:d • 02 ••!"""_•ems 1. 1.
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. .. .. is .. Bodily Injury and Property Daniage Coverage is: • . • ..•,. i.;,, ,• t,;;:;:
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.1i;'1 r : •• . ;: ' 340 SCIOPE OPS COV RAGE.' 'This policy,:If•primary,,atiocds coverage a.t'te�se.-ii t. .� j ..•V
..r • •,.
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. •(i) Insurance Services Ottice form number GL, OW (Eta ..i13)t.C#rrrprelieii»i14:d ti4 • 1_
' �: Lie WIRY Insurance.and lnsvir. r .S•erv.Ices Of five form !lumber GL:(1404 d F
.Ai,:
. 1. •; comprehensive:General Liability zrrerat;..or . . . . . . . . . . l• f 4•'i i lti ti:.
1 i
I;.l:.; ., , (2) Insuraince .S.er/ice.s•Ot•fi •Commercial• General Liatbility Cover* e,► .ocpu"r.Xi *':
.a,;•1. ? : : . , form CO 0001 or "claims•-mode". form CG 6002; or •t'• :t';
JSik+ i . ' is :; l l: i'.{ •1, 1,1'11.
`i. 1, i• l : : :: .: :: :. : (3) If excess, affords coverage which is at least as broad a ' the tsianO, 4lr
.fj }; t ' '. . forms/referenced in the preceding sections (1) and (2 ; • :1 •:1,•.i'•;
Joao
!Li •
MEMBERS OF THE CITY COUNCIL
U COLLENE CAMPBELL
4 1 GARYL.HAUSDORFER
DRUG SA GIL JONES
IMAPORalu CAROLYN NASH
I • fIIAAIISAIYl 1961 JEFF VASQUEZ
0210.L._,11 '
1776 11,
• • CITY MANAGER
GEORGE SCARBOROUGH
March 15, 1994 e4444,4401.
Empire Pipe Cleaning & Equipment, Inc.
P.O. Box 8035
Anaheim, California 92812
Re: Renewal of General Liability and Automobile Liability Certificates of Insurance (City
Sanitary Sewer Line Maintenance)
Dear Gentlemen:
The General Liability and Automobile Liability Certificates of Insurance, regarding the above-
referenced service, are due to expire on April 7, 1994. 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 one of the City approved endorsement forms 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 the April 7th expiration date.
If you have any questions, please contact me at(714) 493-1171 extension 243.
Thank you for your cooperation.
Very truly yours,
/a2),LetA ' riStiM x
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