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1995-1027_BOB WETZEL CONCRETE_Certificate of InsuranceCERTIFICATE OF INSURANCE SUCH INSURANCE AS RESPECTS TVAIPTEREST OF THE CERTIFICATE HOLD SE� MjIY1LL NOT BE CANCELED OR OTHERWISE TERMINATED WITHOUT GIVING 10 D PRIOR WRITTEN NOTICE TO THE CER ATE HOLDER NAMED BELOW, BUT IN NO EVENT SHALL THIS CERTIFICATE BE VALID MORE THAN 30 DAYS FROM THE DATE CITTEIC THIS CERTIFICATE OF INSURANCE DOES NOT CHANGE THE COVERAGE PROVIDED BY ANY POLICY DESCRIBED BELOW. ��' J ?3()This Certifies that: ® STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY of Bloorrongton, Illinois, or Q STATE FARM FIRE AND CASUALTY COMPANY of Blooini gton, Mnols to ;Coverage in force for the following Named Insured as shown below: Named Insured RQR WRT7F,L CUNCBET, INC Address of Named Insured 1419 KEEGAN WAY POUCY NUMBER V53-6909-EO4-55 V53 -2184-F12-55 V53 -6908-F15-55 V53 -6911-C13-55 EFFECTIVE GATE O OF POLICY 05/04/95 06/12/95 FARM INSt R*NCE 06/15/55 450 E 03/13/95 # 10g DESCRIPTION OF '94 Chevy C2500 '94 Chevy S10 "90 Ford F250 '86 Ford F250 VEHICLE UABIUTY COVERAGE [ YES Q NO C YES Q NO YES Q NO ® YES Q No UMITS OF UABIUTY a Bodily Irjury 500,000 500,000 500,000 500,000 Each Person Earn Aaaem 1,000,000 1,000,000 1 0 0 b. Ea arn AWK t 500,000 500,000 500,000 500,000 C. Bodly IrijVy & Ropeny Derrege SMIS Limit Each Accident PHYSICAL DAMAGE] YES Q NO [ YES Q NO Xq YES ONO YES Q NO COVERAGES a. Comprehensive $ 250 Cedric" yr�p250 Deductbe $ 2dO—_ De&W" sem— Deduc" E� YES Q NO M YES Q NO © YES C] NO ® YES Q NO b. Coftion $ 500 Oad..Ub&l y 500 Deductible s 5QQ Deerade $ S.QQ_ Deductble NON-OWNERSHIPYES C7X YES [] NO [ Q NO YES Q NO YES Q No COVERAGE HIRED CAR COVERAGE Q YES [g] NO [] YES ® NO [] YES ® NO C] Y [ NO CQ - STAFF ASSISTANT 8583 08/08/95 Signature df Authorized RepresentarQ 1 Name and Address of Certificate Holder r CITY OF SAN JUAN CAPISTRANO ATTN: DAWN 32400 PASEO ADELANOTO SAN JUAN CAPISTRANO, CA 92675 L Title Agent's Code Nutrer Date J Name and Address of Agent � r DENIS HUDSON, AGENT STATE FARM INSt R*NCE �o 450 E CHAPMAN -AV=E # 10g ORANGE, CA 92666,'-� -n� ^_ �n rn CERTIFICATE HOLDER COPY J CERTIFICATE OF MISIlRp SUCH INSURANCE AS RESPECTS; THE INTEREST OF THE CERTIFICATE M"M WILL IW a CANMW on OTNEMIM TERMINATED WITHOUT GIVING 10 DAYS PRIOR WRITTEN NOTICE TO THE CERTIFICATE HOLM NAMED BELOW. BUT IN N EVENT $HALT. THIS CERTIFICATE BE VAUD MORE THAN 80 DAYS FROM TME DATE WRMEN. THIS CERTWICATE OF INSURANC DOES NOT CHANGE THE COVERAGE PROVIDED BY ANY POLICY DESCRIBED 8EL0W. ryas oMfles that: ® STATE FARM MITRIAL AUTOMOBLP MURAMIX COMPANY d Nowa» rom WMk or M STATE FARM nr*. AND CASUALTY CAMPANY of waomrgaoa, asrols has Morage in torn for thD following Named Insured as shown below: Named Insured BLAB kTgI"LF'r- (71MODFT, INC Address of Nomad Insured 1419 KEEGAN WAY _. POODY NLWBER V53-6909-EO4-55 V53 -2184-F12-55 V53 -6908-F15-55 V53 -6911-C13-55 ^EQqTE DFPoucY 05/04/95 c� 06/12/95 06/15/55 03/13/95 DESCRIPTION OF '94 Chevy C2500 194 Chevy S10 "90 Ford F250 '86 Ford F230 VEHICLE M UABaaiY ODYERAOE [2� Yes o ND In YES n NO Q YM OND ® YE9 Q ND LAMB OF I.NBarFY W. Boors ulcus 500,000 500,()00 500,000 5001000 E■oh Perwn &Wh ApcWW 1,000 2c 1 I ata )00 1 0 npmwtv96 500,000 500,000 500,000 500.000 F Dmega""�Nt Ewh Aaftrd R::] YES YES r- 140 C}� YES 0 NO )PYES MW 5p VM Q NO cavERAaes 250 oaaewlpe Ded CEIe t a — Dea+daa [M YES © NO ® YES n ND ® YES E31W ® Ves 0 ND a Coallon S 501'1 Ded,eetle S 50 Doder.W'16 E JDQ, am -cab S DrAN&& EMPLOYER'S HON-OWHERStup Eil YES El NO Ep YES Q ND Q YM [A to 1'88 Q ND 20 F. HIRED CAR COVERAGE 0 YES. Co NP OYES ® ND []YES k3 ND Q VE'Y (j] ND STAFF ASSISTANT 8583 08/08/95 &Vy 82UM— df Avmonzad ReprqMdoWy TMe AQsWs Gods Number Dab Name and Address of Certificate Holder Name and Address of Agent f' `T f CIW OF SAN JUAN CAPTSTRANO DENIS HUDSON, AGENT ATPN; DAWN STATE FARM INSURANCE 32400 PASEO ADELANOTO 450 E CHAPMAN AVENUE 4 103 SAN JUAN CAPISTRANO, CA 92675 ORANGE, CA 92666 L -i L CERTIFICXM HOMER COpv J sem. c c� - rn _c M �Zy � O J P. 1 0 cormcm of mSUmme SUCH INSURANCE AS RESPECTS THE INTEREST OF THE CERTIFICATE HOLDER TALL HOT BE CANCELED OR OTTERVM TERMINATED VIITHOUT (SVING 10 DAYS PRIOR WRITTEN NOTICE TO THE cEffnwATE HOLM HAMED BELOW, BUT N NC EVENT SHALL THIS CERTIFICATE BE VALID MORE THAN 80 DAYS FROM THE DATE INNITTIBIL THIS CERTIFICATE OF INSURANCE DOES NOT MANGE THE COVERAGE PROVIDED BY ANY POLICY DESCRIBED BELOW. This Garti(dC8 tint: ]® STATE FARM MUTUAL AUTOMOBLE INSURANCE COMIPANY at Bboroingtm undo. or O STATE FARM RRE AND CASWLTY COMPANY of Bborr*Vkx ,anis has oDVerage In force for the fol owing Named Yrslred as Shown below. Named Insured BOB WETZEL CONCRETE INC PoLmy NUMBER 53-6909-BO4-55 V53 -2184-F12-55 V53 -6908-F15-55 V53 -6911-C13-55 EVEOM OF DATE 05-04-95 06-12-95 06-15-95 09-13-95 °ERCAlFrKIIOF VeaCLE 94 CHEVY C2500 94 CHEVY S10 90 FORD F250 86 FORD F250 L A KM COVERAM ® YES o NO ® YES o No ]Elva E3m-- 93vo ONO taars OF LWOUTY a• so " 500,000 500,000 500,000 500,000 E06 Pelson mm Acdomm 1,000,000 1,000,000 1,000;000 110001000 A tifp" barye ESON AOCNM* 500,000 500,000 500 ,000 500,000 SM Awkient PHYSICAL DAMAGE ® YES 0 NO ® YES Q RD Xm To o so C 0 ho COVERAGES 250 2511Dadlidth 250 - 0 stable $-- DaanaNVs ® YES 0 NO ® YES ED RD im Yes El ND Jm Yes 0 ND a tbaebe $ 500 Deaucubl. S 500 Deoicum, $ 500 Dna mob i 500 Doom" EMPLOYER'S NO ® YES Q ND EWES o NO ul Y66 Q NO ® YES a NO FIR® CAR COVEMOEYES inNo 0 YEs ®w o YES m ND ED YES ® NO .�! OFFICE REPRESENTATIVE 8583 10-10-95 Sf�wof Aurhodzed RepresantaUve This Agrsrs COO Nwaher Deft Narm and Address of CaNflcnte Holder Mmm ant! Addrssa of Apnt F- —E IT 7 CITY OF SAN JUAN CAPISTRANO ATTN: DAWN S. DENISE HUDSON 32400 PASHA ADELANTO STAT& FARM I XIMN0 SAN JUAN CAPISTRANO CA 92675 450 E. Clupsuia Ave.. Sift 103 Onow. CA 9$666 ,.'r (714) 63"118 L J L J CCRTIFICATTc HOLDER COPY P. 1 SUCK I`..taMRANCE AS RESPECTS THE INTEREST OF THE CERTIFICATE HOLDER WILL NOT BE CANCELED OR MERWWSE TERMINATED WITHOUT GIVING 10 DAYS PRIOR WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED BELOW, BUT IN NO EVENT $HALL THIS CERTIFICATE BE VALID YORE THAN 30 DAYS FROM THE DATE 1IR I T'TEIL THIS CERTIFICATE OF WBMdRUM DOES NOT CNANOE THE COVERARE PIgVDSD BY ANY POLICY DESCRIBEO BELOW This OBrtffles that ® STATE FARM MUTUAL AUTOMOBILE eisurtANCE COMPANY at Bbw iigEOs, f#sara, or I1 STATE FARM FIRE AND CASUALTY COMPANY of BboftWk L lick hes o0veraye in force for the following Named Insured as shown below: Named Poured BOB WETZEL CONCRETE INC Address of Named Insured 1419 KEEGAN WAY voucYwureen V53 -6909-E04-55 V.53 -2184-F12-55 V53-6908-1715-55 V53 -6911-C13-55 EFFECTNE DATE OF POLICY 05-04-95 06-12-95 06-15-95 03-13-95 DEMORWTION OF vtaft= 94 CHEVY C2500 94 CHEVY SIO 90 FORD F250 86 FORD F250 UABKM COVERAGE © YES Q No El Yffi Q ND M vw ow ® Yes Q No UMITS OF UANUTY a. Bader Y 500,000 500,000 500,000 500,000 1,000,000(1 1,000,000 1,000,000 1,000,000 b' Pep°rn "-"0' 500,0()0 500,000 500,000 500, 000 a w�� AMkwm PHYMAI- VAyAGE Ya Q NO ® YES Q ND ®YES Ow ® YN Q ND COVERAGES a. s--150 Dd„gibW s250 mduaim 250 DK%Nmp -9-_ Dsaamb V1 YES I1 NO ® YES Q No ® YES 0 ND ® YES 0 RD b. Caerbs $ 5Qg–._ Dedt 4 $ 5Q— ps&wd b $ UO&KIRM It 1I x j DaOlaftia _ EMPLOYER'S NRN 4WNEINGHIP r� pri YES Q NO ® YES Q NO ® YES Q NO ® YM Q NO HIRED CAR COVERAGE YES © NO Q YM ® NO Q Yes ® No D YEs ® NO OFFICE REPRESENTATIVE 8583 09-11-95 S%pm&ure of auShodzed Represerdstive lila AWO s Code Number Deas Name and Addfa?s of Certificate Holder Nems and Address of Agent CITY OF SAN JUAN CAPISTRANO ATTN:DAWN S 32400 PASEO ADELANPO DENISE HUDSON SAN JUAN CAPISTRANO CA 92675 STATE FARM INSURANCE 950 R. Chay�n A", See. 103 0—as", CA 92666 (714) 633-6118 L J L CERTIFICATE HOLDER 00" r ACOR�O,in! ��i3sJA DATE IMM/OD YI 8/7/95 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ATHERTON ASSOCIATES ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. COMPANIES AFFORDING COVERAGE 3198—M AIRPORT LOOP COSTA MESA, CA 92626 COMPANY (714) 241-8000 A PACIFIC INSURANCE COMPANY INSURED BOB WETZEL CONCRETE, INC. B FREMONT INDEMNITY 1419 E. KEEGAN WAY COMPANY SANTA ANA, CA 92701 C COMPANY D 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 IMMIDOIYY} DATE (MMIODIYYI GENERAL LIABILITY GENERAL AGGREGATE $1,000,000. X COMMERCIAL GENERAL LIABILITY IOP 0 O O , O O 0 . PRODUCTS CON AGO :5I CLAIMS MADE OCCUR —1 PERSONAL & ADV INJURY SZ , 0 0 0 , 0 0 0 . A OWNER'S&CONTRACTOWSPROT ZI0001573 07/11/95 07/11/96 EACH OCCURRENCE s1, 000, 000. FIRE DAMAGE Any one fire) 5 MED EXP (Any ono person) $ II' AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO ALL OWNED AUTOS BODILY INJURY S l_ SCHEDULED AUTOS IPer person) HIRED AUTOS BODILY INJURY S NON OWNED AUTOS IF., acciDenA —� — - PROPERTY DAMAGE 5 GARAGE LIABILITY AUTO ONLY EA ACCIDENT 5 ANY AUTO 1 OTHER THAN AUTO ONLY. EACH ACCIDENT 5 AGGREGATE 5 EXCESS LIABILITY EACH OCCURRENCE S AGGREGATE $ UMBRELLA FORM _ $ OTHER THAN UMBRELLA FORM WORKERS COMPENSATION AND X T'f IU T OTq EMPLOYERS' LIABILITY EL EACH ACCIDENT $1,000,000. B THEPRGPRIETOR/ INCL WC95-226758-12 03%13%95 03/13/96 EL DISEASE-POucYLIMIT $1,000,000. PARTNERS/EXECUTIVE OFFICERSARE: X EXCL — - - EL DISEASE EA EMPLOYEE $l, 000, 0O0. OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS SEE ATTACHED ADDENDUM REGARDING WORKERS COMPENSATION AS RESPECTS THE GENERAL LIABILITY THE CERTIFICATE HOLDER IS NAMED AS ADDITIONAL INSURED AS RESPECTS THEIR OPERATIONS CER'1`1FkCJ0.TE H4LUER _ _ CANCELLAiT1�N _ _ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE CITY OF SAN JUAN CAPISTRANO EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 32400 PASEO ADELANTO 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, SAN JUAN CAPISTRANO, CA 92675 BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY ^OA UPON kE COMPA , 1 AGENTS OR REPRESENTATIVES. AUTHORIZE EPR NTATIV AOIJRI� zs �s #�.r�;3# "': caRroR;a�#aN �9ae I' 0 0 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED—OWNERS, LESSEES or CONTRACTORS (Form A) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization (Additional Insured): Location of Covered Operations CITY OF SAN JUAN CAPISTRANO Premium Basis Rates Advance Premium Bodily Injury and (Per Property Damage Liability Cost $1000 of cost) $ Total Advance Premium $ (if no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) 1. WHO IS AN INSURED (Section II) is amended to (a) All work on the project (other than include as an insured the person or organization service, maintenance, or repairs) to (called "additional insured") shown in the Sched- be performed by or on behalf of the ule but only with respect to liability arising out of: additional insured(s) at the site of the A. "Your work" for the additional insured(s) at covered operations has been com- the location designated above, or pleted; or B. Acts or omissions of the additional insured(s) (b) That portion of "your work" out of in connection with their general supervision of "your work" at the location shown in the which the injury or damage arises has been put to its intended use by any Schedule. person or organization other than an- t. With respect other contractor or subcontractor engaged in performing operations for tional insureds, the following additional provisions a principal as a part of the same apply: project. A. None of the exclusions under Coverage A, (3) "Bodily injury" or "property damage" except exclusions (a), (d), (e), (f), (h2), (i), arising out of any act or omission of the and (m), apply to this insurance. additional insured(s) or any of their em - B. Additional Exclusions. This insurance does ployees, other than the general supervi- not apply to: sion of work performed for the additional (1) "Bodily injury" or "property damage" insured(s) by you. for which the additional insured(s) are (4) "Property damage" to: obligated to pay damages by reason of (a) Property owned, used or occupied by the assumption of liability in a contract or or rented to the additional insured(s); agreement. This exclusion does not apply toliabilityfordamagesthattheadditional (b) Property in the care, custody, orcon- insured(s) would have in the absence of. trol of the additional insured(s) or over which the additional insured(s) the contract or agreement. are for any purpose exercising phys- " injury" (2)Bodil y in j y" or "property damage" ical control; or occurring after: (c) "Your work" for the additional in- sured(s). CG 20 09 1185 Copyright, Insurance Services Office, Inc., 1984 • LIABILITY ENDORSEMENT • CITY OF SAN JUAN CAPISTRANO 32400 Paseo Adelanto San Juan Capistrano, California 92675 ATTN: A. POLICY INFORMATION Endorsement # 1. Insurance Company PACIFIC INDEMNIFAicyNumber ZI0001573 2. Policy Term (From) to) 7 f 1 6 Endorsement Effective Date 61 3. Named Insured BOB WETZEL CONCRETE INC. 4. Address of Named Insured 1419 E. XEEGAN WAY, SANTA ANA, CA 5. Limit of Liability Any One Occurrence/Aggregate $ 1, 0 0 0, -00 0/ 1, 0 0 0, 0 0 0 General Liability Aggregate (Check One:) Applies "per location/project" Is twice the occurrence limit 6. Deductible of Self -Insured Retention (Nil unless otherwise specified): $ 2,500 7. Coverage is equivalent of Comprehensive General Liability form GL0002 (Ed 1/73) Commercial General Liability "claims -made" form CG0002 8. Bodily Injury and Property Damage Coverage is: :a "claims -made" "occurrence" If claims -made, the retroactive date is VIZII MMM "MUTIrk (!1�� This endorsement is issued in consideration of the policy premium. Notwithstanding any inconsistent statement in the policy to which this endorsement is attached or any other endorsement attached thereto, it is agreed as follows: INSURED, The City, its elected or appointed officers, officials, employees and volunteers are included as insureds with regard to damages and defense of claims arising from: (a) activities performed by or on behalf of the Named Insured, (b) products and completed operations of the Named Insured, or (c) premises owned, leased or used by the Named Insured. 2. CONTRIBUTION NOT REQUIRED. As respects: (a) work performed by the Named Insured for or on behalf of the City; or (b) products sold by the Named Insured to the City; or (c) premises leased by the Named Insured from the City, the insurance afforded by this policy shall be primary insurance as respects the City, its elected or appointed officers, officials, employees or volunteers; or stand in an unbroken chain of coverage excess of the Named Insureds scheduled underlying primary coverage. In either event, any other insurance maintained by the City, its elected or appointed officers, officials, employees or volunteers shall be in excess of this insurance and shall not contribute with it. (OVER) SCOPE OF COVERAGE. This policy, if primary, affords coverage at least as broad as: (1) Insurance Services Office form number GL 0002 (Ed. 1/73), Comprehensive General Liability Insurance and Insurance Services Office form number GL 0404 Broad Form comprehensive General Liability endorsement; or (2) Insurance Services Office Commercial General Liability Coverage, "occurrence" form CG 0001 or "claims -made" form CG 0002; or (3) If excess, affords coverage which is at least as broad as the primary insurance forms referenced in the preceding sections (1) and (2). 4. SEVERABILITY OF INTEREST. The insurance afforded by this policy applies separately to each insured who is seeking coverage or against whom a claim is made or a suit is brought, except with respect to the Company's limit of liability. PROVISIONS REGARDING THE INSURED'S DUTIES AFTER ACCIDENT OR LOSS. Any failure to comply with reporting provisions of the policy shall not affect coverage provided to the City, its elected or appointed officers, officials, employees or volunteers. 6. CANCELLATION NOTICE. The insurance afforded by this policy shall not be suspended, voided, cancelled, reduced in coverage or in limits except after thirty (3 0) days' prior written notice by certified mail return receipt requested has been given to the City. Such notice shall be addressed as shown in the heading of this endorsement. C. INCIDENT AND CLAIM REPORTING PROCEDURE Incidents and claims are to be reported to the insurer at: ATTN: RFGTONAL VT('.F. PRF.STDENT (Title) (Department) FIRST STATE INSURANCE SERVICES (CgrHa9ORTH BRAND BLVD, #1650 (Street Address) GL•ENDALE, CALIF 91203 Cit State ftCode) 81,8-509-7300 ( RI—CITY B OKERAGE, INC.) (Telephone) D. SIGNATURE OF INSURER OR AUTHORIZED REPRESENTATIVE OF THE INSURER JAN DI ANGELO TRELEASE INFORMATION I, (prin nen el w�r�ant that 1 have authority to bpM the below listed insurance company and by m)�gnatu o so bin this comy_y. IGNoaURE OF<4VZH9RfZSD REPRESENTATIVE (original si ature required on endorsement furnished to the City) ORGANIZATION: IATE TITLE: COMMERCIAL LINES UNDERWRITER ADDRESS: 3198 IRPORT LOOP, COSTA TELEPHONE: (71)4-241-8000 MESA, CALIF. 92626