04-0316_ARCHITECT MILFORD WAYNE DONALSON, FAIA_Insurance0 0
Certificate of Insurance
1 of 1 !!73700
Description of Operations/Locations/Vehicles/Restrictions/Special items:
RE: HARRISON HOUSE. GENERAL LIABILITY: ADDITIONAL INSURED ENDT ATTACHED. (CITY OF SAN JUAN CAPISTRANO, ITS ELECTED AND APPOINTED
OFFICIALS AND EMPLOYEES ARE NAMED AS ADDITIONAL INSURED PER EDNT. ATTACHED.
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Agency Name and Address:
Professional Practice
THIS CERTIFICATE IS ISSUED AS A MATTER OF
FORMATION ONLY AND CONFERS NO RIGHTS UPON
Insurance Brokers, Inc.
tHE CERTIFICATE HOLDER. THIS CERTIFICATE DOES
2244 West Coast Highway, Suite 2 �1
Newport Beach, CA 92663 �I •'
NOT AMEND, EXTEND OR ALTER THE COVERAGE
AFFORDED THE POLICIES LISTED BELOW.
32400 Paseo Adelanto
DATE THEREOF, THE ISSUING COMPANY, ITS AGENTS OR REPRESENTATIVES WILL MAIL 30
San Juan Capistrano, CA 92675
Companies Affording Policies:
A, Maryland Casualty Company
e.St. Paul Fire & Marine Insurance Co,
Insureds Name and dress:
Architect Milford Wayne Donaldson FAIA
530 Sixth Avenue
C.WeStport Insurance Corporation
San Diego, CA 92101
D.
E.
F.
Description of Operations/Locations/Vehicles/Restrictions/Special items:
RE: HARRISON HOUSE. GENERAL LIABILITY: ADDITIONAL INSURED ENDT ATTACHED. (CITY OF SAN JUAN CAPISTRANO, ITS ELECTED AND APPOINTED
OFFICIALS AND EMPLOYEES ARE NAMED AS ADDITIONAL INSURED PER EDNT. ATTACHED.
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Certificate Holder:
THE AGGREGATE LIMIT IS THE TOTAL INSURANCE AVMLASLE FOR CLAIMS PRESENTED
WITHIN THE POLICY FOR ALL OPERATIONS OF THE INSURED.
City of San Juan Capistrano
CANCELLATION:
SHOULD ANV OF THE ABOVE DESCRIBED POLICIES BE CANCELED BEFORE THE E%PIILATgN
32400 Paseo Adelanto
DATE THEREOF, THE ISSUING COMPANY, ITS AGENTS OR REPRESENTATIVES WILL MAIL 30
San Juan Capistrano, CA 92675
DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, EXCEPT IN
THE EVENT OF CANCELLATION FOR NON-PAYMENT OF PREMIUM IN WHICH CASE 10 DAYS
NOTICE WILL SE GIVEN.
Aumalzetl Reprssengtiva: y� �./,c 03/04/04
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0 0
Certificate of Insurance
1 of 1 #73700
Description of Operations/LocationsNehicles/Restrictions/Special items:
RE: HARRISON HOUSE. GENERAL LIABILITY: ADDITIONAL INSURED ENDT ATTACHED. (CITY OF SAN JUAN CAPISTRANO, ITS ELECTED AND APPOINTED
OFFICIALS AND EMPLOYEES ARE NAMED AS ADDITIONAL INSURED PER EDNT. ATTACHED.
•UH.itta., ata ata limit* n/ linhilih, not Ia** than amn.Int *hnwn
Certificate Holder:
THE AGGREGATE LIMIT IS THE TOTAL INSURANCE AVAILABLE FOR CLANS PRESENTED
Agency Name and Address:
THIS CERTIFICATE IS ISSUED AS A MATTER OF
Professional Practice
INFORMATION ONLY AND CONFERS NO RIGHTS UPON
Insurance Brokers, Inc.
THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES
2244 West Coast Highway, Suite 200
NOT AMEND, EXTEND OR ALTER THE COVERAGE
Newport Beach, CA 92663
AFFORDED THE POLICIES LISTED BELOW.
THE EVENT OF CANCELLATION FOR NONPAYMENT OF PREMIUM IN WHICH CASE 10 DAYS
Corrgmles Affording Policies:
AMaryI It Casualty Company
B.St. Paul Fire &Marine Insurance Co.
Insureds Name and Address:
Architect Milford Wayne Donaldson FAIA
530 Sixth Avenue
c.Westport Insurance Corporation
San Diego, CA 92101
D.
E.
F.
Description of Operations/LocationsNehicles/Restrictions/Special items:
RE: HARRISON HOUSE. GENERAL LIABILITY: ADDITIONAL INSURED ENDT ATTACHED. (CITY OF SAN JUAN CAPISTRANO, ITS ELECTED AND APPOINTED
OFFICIALS AND EMPLOYEES ARE NAMED AS ADDITIONAL INSURED PER EDNT. ATTACHED.
•UH.itta., ata ata limit* n/ linhilih, not Ia** than amn.Int *hnwn
Certificate Holder:
THE AGGREGATE LIMIT IS THE TOTAL INSURANCE AVAILABLE FOR CLANS PRESENTED
WITHIN THE POLICY FOR ALL OPERATIONS OF THE INSURED.
City of San Juan Capistrano
CANCELLATION:
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELED BEFORE THE EXPIRATION
32400 Paseo Adelanto
DATE THEREOF, THE ISSUING COMPANY. ITS AGENTS OR REPRESENTATIVES WILL MAIL 30
San Juan Capistrano, CA 92675
DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, EXCEPT IN
THE EVENT OF CANCELLATION FOR NONPAYMENT OF PREMIUM IN WHICH CASE 10 DAYS
NOTICE WILL BE GIVEN.
Ata,pIalO Repw n: - 03/04/04
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NAME INSURED: ARCHITECT MILFORD WAYNE DONALDSON FAIA
POLICY NUMBER: PAS41527293 CL 246
(11-85)
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CG 2010 11 85
ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS (FORM B)
This endorsement modes insurance provided under the following:
COMMERCIAL GENERAL LIABHdTY COVERAGE PART
SCHEDULE
Name of Person Or Organization:
CITY OF SAN JUAN CAPISTRANO, ITS ELECTED AND APPOINTED OFFICIALS
AND EMPLOYEES
(If no entry appears above, information required to complete this endorsement will be shown in
the Declarations as applicable to this endorsement.)
WHO IS AN INSURED (Section II) is amended to include as an insured the person or
organization shown in the Schedule, but only with respect to liability arising out of "your work"
for that insured by or for you.
CORA LIM FOR P.P.I.B.
XCG2010 Copyright, Insurance Service Offices, Inc., 1984