1993-1108_EMPIRE PIPE CLEANING & EQUIPMENT_Insurance Certificate EF CSR ISSUE DATE(MM/DDNY) •
A/.11�.11 CERTIFICA OF INSURANCE 11/08/93
EMPIR-1
PRODUCER f THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
BOSWELL 'TNSURANCE AGENCY CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE
Agents tBrokers, Inc. DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
P.O. Box 4648 POLICIES BELOW.
Mission Viejo CA 92690
COMPANIES AFFORDING COVERAGE
Joe A. Boswell
714-855-0430 LETTERNY A Golden Eagle Insurance Company
COMPANY
INSURED LETTER B /(/ D
IIIYYY
COMPANY (+
LETTER
Empire Pipe Cleaning & COMPANYD 7:1-1 rn
Equipment, Inc. LETTER -‹
P.O.
n
P.O. Box 8035 -: T-I
Anaheim CA 92802 COMPANY E
LETTER ;zrn (fib rn
COVERAGES ' ; :>
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY��IOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHIC} 1IS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TEFR11�015$�
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 $
COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGO. $
CLAIMS MADE OCCUR. PERSONAL&ADV.INJURY $
OWNER'S&CONTRACTOR'S PROT. EACH OCCURRENCE $
FIRE DAMAGE(Any one fire) $
MED.EXPENSE(Any one person) $
AUTOMOBILE LIABILITY COMBINED SINGLE
ANY AUTO LIMIT $
ALL OWNED AUTOS
BODILY INJURY
SCHEDULED AUTOS (Per person)
HIRED AUTOS
BODILY INJURY $
NON-OWNED AUTOS (Per accident)
GARAGE LIABILITY
PROPERTY DAMAGE $
EXCESS LIABILITY EACH OCCURRENCE $
UMBRELLA FORM AGGREGATE $
OTHER THAN UMBRELLA FORM
A WORKER'S COMPENSATION PWC20732201 11/01/93 11/01/94 STATUTORY LIMITS
AND EACH ACCIDENT $ 1,000,000
DISEASE—POLICY UNIT $ 1,000,000
EMPLOYERS'LIABILITY
DISEASE—EACH EMPLOYEE $ 1,000,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
*Except 10-days for nonpayment or reporting.
All Operations of Named Insured
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL 40AVO{1{Qt}{
MAIL 30* DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
City of San Juan Capistrano LEFT,Wilkli@fiCA-9**k§k§t}/CWitTiClc-X0**§4-AtFiagi497PRW§VkTiqMik
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Community Redevelopment Agency
32400 Paseo Adelanto L NIE<RFx9t AR9k R 'x AREAIRRRR kT Rx
San Juan Capistrano CA 92675 AUTHORIZED REPRESENTATIVE
Joe A. Boswell tolth
4. ►.'' /
ACORD 25-S(7/90) QAC«H p ..;. .RPORAT QN 1990.
4)Kee
•
•I• yep,` - MEMBERS OF THE CITY COUNCIL
�4 1- COLLENE CAMPBELL
GARY L.HAUSDORFER
m96T" GIL JONES
N NASH ASH
JEFF VASQUEZ
‘21. "' 1776
• �' • CITY MANAGER
GEORGE SCARBOROUGH
October 29 , 1993
Empire Pipe Cleaning & Equipment Co.
P.O. Box 8035
Anaheim, California 92812
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, 1993 .
In accordance with your agreement, the insurance certificate needs
to be renewed for an additional period of one year.
Please forward the updated certificate to the City, attention City
Clerk' s office, by November 15th.
If you have any questions, please contact me at (714) 493-1171
extension 243 .
Thank you for your cooperation.
Very
� truly yours,
�a..�(, g •k ey
Dawn M. Schanderl
Deputy City Clerk
cc: Cheryl Johnson, City Clerk
Nancy Barney, Public Land & Facilities
32400 PASEO ADELANTO, SAN JUAN CAPISTRANO, CALIFORNIA 92675 • (714) 493-1171