The URL can be used to link to this page

1997-0701_BOYS & GIRLS CLUBS OF CAPISTRANO VALLEY_Insurance bl l . ✓Q SG STATE P.O. BOX 807, SAN FRANCISCO,CA 94101-0807 COMPENSATION INSURANCE FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE POLICY NUMBER: 1381364 - 00 ISSUE DATE: 01-01-00 CERTIFICATE EXPIRES: 01-01-01 CITY OF SAN JUAN CAPISTRANO JOB: ALL OPERATIONS BUILDING & SAFETY DEPARTMENT 32400 PASEO ADELANTO SAN JUAN CAPISTRANO, CA 92675 This is to certify that we have issued a valid Workers' Compensation insurance policy in a from approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the fund except upon 10 days' advance written notice to the employer. We will also give you 10 days' advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies listed herein. notwithstanding any requirement, term, or condition of any contract or other document with respect to which this certificate of insurance 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. PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000.00 PER OCCURRENCE. L s c rn vo's� QD m �nrn� v fT1 O O EMPLOYER LEGAL NAME BOYS AND GIRLS CLUB OF CAPISTRANO BOYS AND GIRLS CLUB OF CAPISTRANO VALLEY VALLEY (A NON-PROFIT PUBLIC BENEFIT CORP) 31371 EL CAMINO REAL, S J CAPISTRANO CA 92675 PRINTED: 12-19-99 P0408 DOCUMENTTHIS .i 1 r . s . e CIL.' 40 l 32400 PASEO ADELANTO MEMBERS OF THE CITY COUNCIL SAN JUAN CAPISTRANO.CA 92675 �'� . � � COLLENE CAMPBELL JOHN GREINER (949)493-1171 ' uurnitu WYATT HART (949)493-1053 (FAX) GIL JONES 1776 DAVID M.SWERDLIN CITY MANAGER GEORGE SCARBOROUGH December 27, 1999 Mr. James L. Williams, Executive Director Boys and Girls Club of Capistrano Valley 31371 EI*Camino Real San Juan Capistrano, California 92675 Re: Renewal of Workers' Compensation Certificate of Insurance (After School Recreation Programs/Real Property Lease Agreement) Dear Mr. Williams: The Workers' Compensation Certificate of Insurance, regarding the above-referenced agreements, is due to expire on January 1, 2000. In accordance with your agreements, 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 January 10, 2000. If you have any questions, please contact me at (949) 443-6310. Thank you for your cooperation. Very truly yours, Dawn M. Schanderl Deputy City Clerk cc: Cheryl Johnson, City Clerk Karen Crocker, Community Services Manager DRUG USE is San Juan Capistrano: Preserving the Past to Enhance the Future -NOV-23-1999 TUE 12:42 PM MANION BELL INSURANCE FAX NO. 213 389 5833 P. 03 r� a.:J.>>.:J..o-.i:'>�:..........j::..4..•.\.:a::.. .%•.•`i ,1. f .', .• (( : J x.K.r,;xr;•;.1�.:.1.<..�.�...a'-ra:a>•,tvr •yl'..xcwa. •;l` I�:(i:'{'(. .y A -p} l �.,. Iolit99 .. •r'. •. '•: {,•:,.i:.. 0...>v.J:,•:' I,a;'>' 7•h W►:1•rxa•.,: •.v..a"..rw•w••x•If..! t•%:s•�Y.•va:A'4:»;� Producer THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ry MANION/BELL INSURANCE ASSOCIATP.S ONLY AND CONFERS NO AIGHTS UPON THE CERTIFICATE P. O. BOX 36186 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR LOS ANGELES, CA. 90036 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW (213)387-8294*FAX(213)389-5833 COMPANIES AFFORDING COVERAGES . LIC.0 0655274 Company niured - A MARKEL INSURANCE COMPANY Company BOYS AND GIRIS CLUB OF CAPISTRANO VALLEY B 31371 FL CAM INO REAL Company •_-- — SAN JUAN CA,PISTRANO,CA.92675 C COwapany ». D ;NJ� ':;,:w.,l: ::cx;Y;'(��(:' ..w:•x.w..I•.:iC(:�:.�:!:::::.-:e.::M:. �r!``(t .:i�:= �f•rer.n.r:•;J:.•:a:rrc:r-Yy. x:.e.<a- •:r:a ••..:.: w.,: f•�>.�• /�( :.•v• 1.•• ^'t•>r. .<J..,.a• r;.•w•xTx7t)' .>:?::t••(� ...f.tl-wL..x:t.••1% .i�!:^:!. .t•:' + •i.•��•:�::w ::t•:t• {:•�•••::•,;.,;:%:,,.x: ..J.Y..: ,i y��>>,> yM:1>�;•.;t. )'•�: )%..r...>.Y.t•'1'►:,:�:.rr•:Y..<r K•^�>:..;.. wYw••...a.x.,,:a_M;:(�l,^ ).;. .r•f1•,.x.A•>>•.1r .y.�;:;:,...I••':lx .i x.*.1: Ir.w.•<;:t..r.v,C):<r...., •;':;.1:',,.y.��.:5 ' 7�w1M , '�'.•. Jill,• .b:tJ,a 31•P.. .•{`' ..2:::r.:.M>:.N 7* AY:aY .:t a w:::.. r(•:t •:•...•�:�w:.Y..:YwruJ.ta:iit�:•,t•.i..:!).... .v.:..a..:.•Jl•K:a:nT:l�:;�:.�..•..v...A.•..•.e..[.x�>:!`�...!>A,>,:::�:i�:Z..w�.„wJt�.:•:�:Ct;:�...a.......•. •..a•tof:�..w>t�;'•` '. :.•wa••::"Yd'!, ) l;.%:t.... THIS 19 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE @EF.N ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OA OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY Be ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SUBJECT TO ALL YHE TERMS, EXCLUSIONS AND CONDITIONS Of SUCH POLICIES. LIMIYS SHOWN MAY HAVE BUN REDUCED OY PAID CLAIMS, Co POLICY -'•— --- LTR TYPE OF INSURANCE NUM901 INCCPTI>ON RXPMATWM LIMITS A . comm.omrw 11AMMY 850.2CY009-485 11/1/99 11/11/00 GENERAL AGGREGATE $3,000,000.00 cultNLncE FORM ontrp PRODUCTS-COMP/OP AGG 01,000,000,00 onPERSONAL&ADV INJURY $1,000,000,00 EACH OCCURRENCE $1,000,000.00 FIRE DAMAGE(Any ors*fire) _$_50,000.00 (EXCLUDING MEMBERS AND STAFF) MED EXPlAny one person) $5,000.00 AUTOMOBILE LIABILITY ANY AMrrp - COMBINED SINGLE LIMIT ALI 0wn10 AU105 E10DILY INJURY � tiCHEOULF0 AUTOS — — _ (Per person) 1191101 A1006 BODILY INJURY NON•Owhrp ALIT05 F (Per accidont) ACV Comprehampvc&COIIISIOA less=250.Deductible SCHEDULED VEHICI-E SHOWN BELOW •r. — - - PROPERTY DAMAGE EXCESS LIABILITY EACH OCCURRENCE UMMILLLLA FOAM AGGREGATE ~� -- - QTNE4 TITAN UMMREI.IArORM —^, - -------- ACCIDENT --- -ACCIDENT COVe1tAGE MED LIMIT •,-•----•— -- WIMARY SICKNESS 1"ItIlss DEDUCTIe" IOTHEA ••••• wwJ-__ WSCRIPTTOA OF OKRA T10?"1LCCATZON3NEj4CILil3/[CIAL ITTUt Certificate Holder is included as additional insured but only as respects the operations of the Named Insured performed. —Re: After School Recreation Programs/Real Property Lease Agreement :c:.-:-- <.'::- --..-max......•,..-- 11'T `', l!•AM,. �•a.-< > �1•.,..•Y •>, > -�.i%.,-Y C, I. �ww�'..�i'<>:.>'-•:: .r r• ..,`. x-xv><.:•:. -kf.xr. >. a +e,-�wy�t. 1��l,> < •:s'...i- - � `_ _ f.. <. :<•. .•>_.<.x-%.�t�a` �M�7lfF;.7t.�x 7`-•'�'a ->.- .<.! ) .•� (a, ,.. �>.f>..(<w f>� w�� Z..>l. a: SHOULD ANY OFTHE ADOVC DIOW-RIBED POLICIL::S Rh CANCELED DI!M- ft1:THY- City of San Juan Capistrano EXPIPAT10N DATk,ri4ERFQF,THE ISSUING COMPANY WILL MAIL 30 DAYS It's officers, agents and employees WRRTF.NNOTICE TUTIILCVRTI9CATj3HOLDER NAMED TOTIM!LErr(.,cc.pt 32400 Paso A Delanto in cast of nnn-payment of premium whcmin a 10 day pt)ticc will San Juan Capistrano, CA 92675 be iven). _ AUTllonim 11CPRESENTATIVE -NOW-23-1999 TUE 12:42 PM MANION BELL INSURANCE FAX NO. 213 389 5833 P. 04 (7)• .POLICY NUMBER: e502Crt0084e5 � COMMERCIAL GENERAL. IA8ILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ 1T CAAEFt!!.L , ADDITIONAL INSURED -P.- DESIGNATED PARSON R ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. Name of Parson or Organization: SCHEDULE City of Sen Juan Capistrano its officers, agents and employees (If no entry appears above, information required to complete this Declarations as applicable to this endorsement.) endorsement will be shown il the WHO IS AN INSURER Section ll) Is amended to Include ae an insured Schedule as an Insured but only with respect to liability arising out of the person or organization shown n the rented to you. your operations or promisee owned by or CG 20 26 11 85 Copyright, Insurance services Office, Inc., 1984 d / SG STATE P.O. BOX 807, SAN FRANCISCO,CA 94101-0807 6� •" 30 �J COMPENSATION Olr�'lyi L �j G�hOGJ I FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE POLICY NUMBER: 1381364 - 99 ISSUE DATE: 01-01-99 CERTIFICATE EXPIRES: 01-01-00 CITY OF SAN JUAN CAPISTRANO JOB: ALL OPERATIONS BUILDING & SAFETY DEPARTMENT 32400 PASEO ADELANTO $AN JUAN CAPISTRANO, CA 92675 This is to certify that we have issued a valid Workers' Compensation insurance policy in a from approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the fund except upon 10 days' advance written notice to the employer. We will also give you 10 days' advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies listed herein. notwithstanding any requirement, term, or condition of any contract or other document with respect to which this certificate of insurance 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. 2 �PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000.00 PER OCCURRENCE. O r., c� c» m I.l O LG EMPLOYER LEGAL NAME BOYS AND GIRLS CLUB OF CAPISTRANO BOYS AND GIRLS CLUB OF CAPISTRANO VALLEY VALLEY (A NON-PROFIT PUBLIC BENEFIT CORP) 31371 EL CAMINO REAL, S J CAPISTRANO, CA 92675 PRINTED: 12-18-98 P0408 .1 T771,7171 I) ISSUE DATE(MM/DD/YY) r Aco11QR) (: CFRTI� CATF INSl1RANOE -17-1998 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS Markel Insurance Company NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, P.O. BOX-3870 EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Glen Allen, VA 23058-3870 COMPANIES AFFORDING COVERAGE COMPANY CODE SUB-CODE LETTER A MARKEL INSURANCE COMPANY Z COMPANY B INSURED LETTER y. t'V Boys&Girls Club of Capistrano Valley COMPANYC }: rn 31371 EI Camino Real LETTER San Juan Capistrano, CA 92675 COMPANY D CD .0 LETTER ^' '.�," t!—+ rn COMPANY E LETTER ::>• :::; 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 SUN POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY O POLICY EFFECTIVE POLICY EXPIRATION TYPE OF INSURANCE POLICY NUMBER LIMITS _TRDATE(MM/DD/YY) 'DATE(MM/DD/YY) A GENERAL LIABILITY GENERAL AGGREGATE 8 3,000,000 X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OPS AGGREGATE 8 1,000,000 CLAIMS MADE rX OCCUR. g502CY009485-4 11-01-1998 11-01-1999 PERSONAL&ADVERTISING INJURY 6 1,000,000 OWNERS&CONTRACTOR'S PROT. EACH OCCURRENCE 8 1,000,000 FIRE DAMAGE(Any one fire) 8 100,000 MEDICAL EXPENSE(Any one person) 8 51000 AUTOMOBILE LIABILITY COMBINED SINGLE 8 ANY Auto LIMIT ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per Person) 8 HIRED AUTOS BODILY INJURY 8 NON-OWNED AUTOS (Per accident) GARAGE LIABILITY PROPERTY DAMAGE $ EXCESS LIABILITY EACH OCCURRENCE 8 UMBRELLA FORM AGGREGATE 8 OTHER THAN UMBRELLA FORM STATUTORY LIMITS WORKER'S COMPENSATION EACH ACCIDENT 8 AND DISEASE-POLICY LIMIT 8 EMPLOYERS'LIABILITY DISEASE-EACH EMPLOYEE 8 A OTHER Crime 8502CY009485-4 11-01-1998 11-01-1999 DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/SPECIAL ITEMS Certificate holder is included as additional insured for operations conducted by the named insured. CERTIFICATE`HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO City of San Juan Capistrano MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION its officers,agents and employees OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR 32400 Paso A Delanto REPRESENTATIVES. San Juan Capistrano,CA 92675 AUTHORIZED REPRESENTATIVE Bruce A. Kay VPO ACORD 25-S(7190) (c) ACO CORPORATION 1990. +POLICY NUMBER: 8502CY06,.,,85 • 4 �MMERQAL GFKIPRA4 LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: o C COMMERCIAL GENERAL LIABILITY COVERAGE PART. r� -L n SCHEDULE __ - -} w M _. c,�.� < Name of Person or Organization: ^ City of San Juan Capistrano a �� its officers, agents and employees m (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 as an insured but only with respect to liability arising out of your operations or premises owned by or rented to you. CG 20 26 11 85 Copyright, Insurance Services Office, Inc., 1984 POLICY NUMBER: 8502CY009485 - 4 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: Capistrano Unified School District Board of Trustees (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 ll) is amended to include as an insured the person or organization shown in the Schedule as an insured but only with respect to liability arising out of your operations or premises owned by or rented to you. CG 20 26 11 85 Copyright, Insurance Services Office, Inc., 1984 C. DEC 08 "98 03:48PH-B ANI-Li�B 1=:AP,:1 P. 1. 1 1 ` °t r% - RECEIVED 52440 PASEo AoEU4NTo Q t IE1l9Ei+S OF CO LE r C CCuI:,,�L SAN JUAN CAPISTRANO,CA 92675 11, {L�11 4 3•l C7LlEnS Ca:r.PEEL. QQQ(� ,ICHN GREINEF (949)493.1 171 jij • �u•1nuu: ' �JU wYATTHART (949)49►-1459(FAX) 11110111116 GiLJIDNEZ 1776 I)AVIC M.$VI=F.mm . tf i'.�,f,.+ y: j,JTY GER L.1 �' CI MANAGER SCARGOROUGH • JU/,fir �: •. ,• December 7, 1998 prg ad 1398 Mr. Jim Williams, Executive Director Boys &Girls Club of Capistrano Valley 31371 EI Camino Real San Juan Capistrano, California 92675 Re: After School Recreation and Teen Programs Dear Mr. Williams: At their meeting of December 1, 1998, the City Council of the City of San Juan Capistrano took action to approve an extension of the After School Recreation and Teen Program agreements. The agreements will continue in effect for a six-month period ending June 30, 1999. The insurance required by the contracts has been received with the exception of the liability endorsement form naming both the City and the Capistrano Unified School District as additional insured. Please forward the endorsement form to the City Clerk's office as soon as possible. We would also like to bring to your attention that the required Worker's Compensation certificate will expire on January 1, 1999 and a renewed certificate•will_be needed. Thank you for your assistance. Please feel free to contact Karen Crocker at 443-6389 if you have any questions. Very truly yours, IL & EQUEST<-2) Please... To: r ead Cheryl Johnson I, •,tet�,; ` ndle City Clerk Zn Approve cc: Karen Crocker rForwar From: ❑ Retum ❑ Keep or Toss ❑ Review with Me Date: M .11.11717.11.inr7 (''Imstn ann• Prpsnr v na .__.. SG STATE P.O. BOX 807, SAN FRANCISCO,CA 94101-0807 COMPENSATION INSURANCE FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE POLICY.NUMBER: 1381364 - 98 ISSUE DATE: 01-01-98 CERTIFICATE EXPIRES: 01-01-99 CITY OF SAN JUAN CAPISTRANO JOB: ALL OPERATIONS BUILDING & SAFETY DEPARTMENT 32400 PASEO ADELANTO SAN JUAN CAPISTRANO, CA 92675 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 10 days' advance written notice to the employer. We will also give you 10 days' advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document with respect to which this certificate of insurance 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 p�_'ollliicciiie'ss.j��/�/ PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: 81 ,.000,000.00 PER OCCURRENCE. L a x - N m 0 N M _-Jrn co w EMPLOYER .LEGAL NAME BOYS AND GIRLS CLUB OF CAPISTRANO BOYS AND GIRLS CLUB OF CAPISTRANO VALLEY VALLEY (A NON-PROFIT PUBLIC BENEFIT CORP) 31371 EL CAMINO REAL, S J CAPISTRANO, CA 92675 12-18-97 PRINTED: PO THIS DOCUMENT • SCIF 10265(REV.. STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807 COMPENSATION INSURANCE FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE APRIL 7 , 1997 POLICY NUMBER: 1381364 - 97 CERTIFICATE EXPIRES: 1 -1 -98 F- CITY OF SAN JUAN CAPISTRANO BUILDING & SAFETY DEPARTMENT 32400 PASEO ADELANTO SAN JUAN CAPISTRANO , CA 92675 JOB : 1 . TEEN RECREATION 2 . AFTER-SCHOOL RECREAT . EMPLOYEES=2 I_ This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon ten days'advance written notice to the employer. We will also give you TEN days'advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document with respect to which this certificate of insurance 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. AUTHORIZED REPRESENTATIVE PRESIDENT EMPLOYER ' S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1 ,000 ,000 PER OCCURRENCE r_ m C Cm 0 4 a Q EMPLOYER F BOYS AND GIRLS CLUB OF CAPISTRANO VALLEY 31371 EL CAMINO REAL SAN JUAN CAPISTRANO, CA 92675 THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND A %i I% k111lII� ffill % l� I • •• • 11/6/97N.. EX," Producer THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION MANION/BELL INSURANCE ASSOCIATES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.U. BOX 36186 HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR LOS ANGELES,CA.90036 1 ALI tR THE CUVP9.11'GE AFFO.-ltU BY THE POLICIES BELOW COMPANIES Ah;OHDIF-ju-UOVLKAGES LIC.ft 0655274 Company Insured A MARKEL INSURANCE COMPANY Company BOYS AND GWJ_S CLUB OF CAPISTRANO VALLEY B 31371 EL CAMINO REAL Company SAN JUAN CAPISTRANO.CA.92675 C Company _D . ......... %; n R I,�Ell Rw 12-*r 10 'X* 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 POLICY LTR TYPE OF INSURANCE NUMBER INCEPTION EXPIRATION LIMITS A X COMM.GENERAL LIABILITY 8502CY009-"5-3 11/l/97 11/l/98 GENERAL AGGREGATE $1,000,000 OCCURRFNCE FORM PRODUCTS*COMPIOP AGG $3,000,000 OTHER PERSONAL&ADV INJURY $1,000,000 EACH OCCURRENCE $1,000,000 FIRE DAMAGE(Any one fire) $50,000 (EXCLUDING MEMBERS AND STAFF) MED EXP(Any one person) $5,000 AUTOMOBILE LIABILITY HANN AUsO jv;U-,'ABINLU I ALL nvl%j'!C SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE EXCESS LIABILITY EACH OCCURRENCE UMBRELLA FORM AGGREGATE OTHER THAN UMBRELLA FORM ACCIDENT COVERAGE MED LIMIT PRIMARY SICKNESS EXCESS DEDUCTIBLE DEDUCTIBLE OTHER OTHER DESCRIPTION OF OPERATIONS/LOCATIOPOS/VERICLESISPECtAL ff EMS CERTIFICATE HOLDER IS ADDED AS ADDITIONAL INSURED WITH REGARD TO LIABILITY ARISING OUT OF use of premises. .......... 1, 11,OR— w My SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL City of San Juan Capistrano 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, 32400 Paseo Adelanto BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY San Juan Capistrano, CA 92675 OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE MANION / BELL Insurance Associates LICENSE 0655274 October 27, 1997 Page 2 Mr. James L. Williams, Executive Director, Boys and Gids Club of Capistrano Valley re: Insurance -Renewal Proposal 2) COMMERCIAL GENERAL LIABILITY INSURANCE Limit of Liability per Occurrence $ 1,000,000.00 General Aggregate (maximum payable during policy term) 3,000,000.OJ per Occurrence $ 1,000,000.00 AND Annual Aggregate $ 1,000,000.00 Fire Legal Liability $ 100,000.00 Premises Medical Payments (excludes Club Members) $ 5,000.00 Sexual Abuse Liability'Sublimit per person $ 1,000,000.00 aggregate (max. payable during policy term) $ 1,000,000.00 Premium is based on: Loc. 1: 31371 EI Camino Real, San Juan Capistrano Club Building with square footage use of 2,500, with 125 members and additional insured endorsements to various entities for use of property Loc. 2: 32101 Camino Capistrano, San Juan Capistrano Thrift Store with estimated annual receipts of$50,000. additional insured endorsement to Lessor Loc. 3: Loc. 3: 25601 Camino del Avion, San Juan Capistrano, CA (Club) Youth Renreationprogr-a..m with 15 Repisttants continued 'to continue this coverage you need to 1)run a background check on all employees, (see attached Brochure on CA Hotline) 2) develop a plan of monitoring staff in day to day relationships with members and 3) develop a "Crisis Management Plan"to deal with an incident of abuse. 849 Third Avenue • Los Angeles, CA 90005.- (213) 387-8294 • Fax(213)389-5833 Pleave rPrer 1n ]An nnlirrr v rin]nilr•�f�mrnvnr•n .pt•q jr••nnC Oul rrq/ncinnc Page 2 Agenda Item -3- June 15, 1999 ALTERNATE ACTIONS: 1. Approve the renewal of the Afterschool Recreation and Teen Program agreements between the City of San Juan Capistrano and Boys & Girls Club of Capistrano Valley, Inc. for the period July 1, 1999 through June 30,2000. 2. Continue the item,and direct staff to return with additional information on specified issues. RECOMMENDATION: By motion,approve renewal of the Afterschool Recreation and Teen Program agreements between the City of San Juan Capistrano and Boys & Girls Club of Capistrano Valley, Inc. for the period July 1, 1999 through June 30,2000. Respectfully submitted, Al King, Jr. Community Services Director AK:jtb Attachments A. Current Afterschool Recreation Program Agreement with Boys& Girls Club B. Current Teen Program Agreement with Boys&Girls Club C.— Amendments. Amendments to Agreements cA...lwpdocs12451aiccbg.agm Agenda Item -2- June 15, 1999 Once the teen program position is filled,the Club will resume providing this service with the beginning of the September 1999 school year. Staff is recommending that the City Council approve the renewal of agreements for both the afterschool recreation and Friday afterschool teen programs with the Boys&Girls Club of Capistrano Valley.Terms,conditions,and dollar amounts would remain as currently funded, with the renewed agreements being effective July 1, 1999-June 30,2000. COMMISSION/BOARD REVIEW,RECOMMENDATION: This item was presented to the Parks,Recreation&Equestrian Commission on May 17, 1999. The Commission recommended unanimously that the City Council approve the renewal. FINANCIAL CONSIDERATIONS: The afterschool recreation program to be conducted at the Boys&Girls Club facility at Serra School is funded as a part of the department's fiscal year 1999-2000 budget request in the amount of $13,868,invoiced monthly from the contractor at$1,155.67.Funding for the Friday afterschool teen program,Fabulous Fridays,has been incorporated in the department's fiscal year 1999-2000 budget request in the amount of$4,217 annually and will be invoiced monthly at a rate of$351.42. These dollar amounts have remained the same, with no projected increase over the term of this renewed agreement. NOTIFICATION: Jim Williams, Executive Director Jim Sieger, Principal Boys & Girls Club of Capistrano Valley, Inc. Marco Forster Middle School 31371 El Camino Real 25601 Camino del Avion San Juan Capistrano, CA 92675 San Juan Capistrano, CA 92675 Tony Brown,President San Juan Community Task Force 31421 La Matanza San Juan Capistrano, CA 92675 AGENDA ITEM June 15, 1999 TO: George Scarborough, City Manager FROM: Al King,Jr., Community Services Director SUBJECT: Consideration of Renewal of Agreements for Afterschool Recreation and Teen Programs(Boys&Girls Club of Capistrano Valley,Inc.) RECOMMENDATION: By motion,approve renewal of the Afterschool Recreation and Teen Program agreements between the City of San Juan Capistrano and Boys & Girls Club of Capistrano Valley, Inc. for the period July 1, 1999 through June 30,2000. SITUATION: A. Background: Current agreements with the Boys&Girls Club of Capistrano Valley to provide afterschool recreation(Attachment A)and teen programs(Attachment B)will expire June 30, 1999.The Boys&Girls Club has been under contract to provide these important youth programs and services to the community since July 1, 1997,for an initial 18-month period,which received a six-month extension in December 1998 through June 30, 1999. B. Summary and Recommendation: The Boys & Girls Club of Capistrano Valley has been providing an increased level of afterschool recreation programs at the existing Boys&Girls Club facility and has been under contract with the City as an afterschool recreation and programs provider since July 1, 1997. This program has been tremendously successful in increasing participation levels as well as broadening program and service offerings to elementary and middle school age youth. Additionally,the Club has also sought to conduct a Friday afterschool teen program at Marco Forster titled "Fabulous Fridays." Difficulties in obtaining qualified staff to conduct this program at Marco Forster Middle School have prevented the program from taking place for much of this current 1998-99 fiscal year. This has resulted in cost savings to the City. The Club and the City are very desirous of Fabulous Fridays taking place during the upcoming fiscal year 1999-2000,and both staff and the Club are recommending the continuation of this program as a part of the contract renewal process. FOR CITY COUNCIL AGEN . .. �. MEMBERS OF THE CITY COUNCIL C � 01 COLLENE CAMPBELL J JOHN GREiNER IRfItlCtlfEl WYATT HART ESiltll{tEl 1961 GIL JONES 176 DAVID M.SWERDLIN CITY MANAGER GEORGE SCARBOROUGH March 20, 1997 Mr. James L. Williams, Executive Director Boys & Girls Club of Capistrano Valley, Inc. 31371 EI Camino Real San Juan Capistrano, California 92675 Re: After School Recreation Program Dear Mr. Williams: At their meeting of March 18, 1997, the City Council of the City of San Juan Capistrano approved agreements with the Boys & Girls Club of Capistrano Valley to provide an after school program Monday-Friday at the club facility for boys and girls ages 6-16; and, to provide a teen program on Fridays at Marco Forster Junior High School for boys and girls in grades 6-8. The Agreements will be effective.for an 18-month period beginning July 1, 1979 and ending December 31, 1998. The City has received the required;insurance, with r� the exception of the ion certIMMWand the liability endorsement form. Please forward those documents to the City Clerk's office as soon as possible. Fully-executed copies of the Agreements are enclosed for your files. Thank you for your interest in providing these services. Please feel free to contact Karen Crocker, Community Services Manager at 443-6389 if you have any questions. Very truly yours, Cheryl Johnson City Clerk Enclosure 1 1,��.. �},� C �rZ� cc: Karen Crocker ,r.-- l �'` , a' °�� alu Je aj- .. ,, .,. n . ., , •. 1 1('i\r' I l n .l.) -"7r ,1 (71st� 1n^, � MEMORANDUM December 3, 1997 • TO: Dawn Schanderl, Deputy City Clerk FROM: Karen Crocker, Community Services Manager SUBJECT: Boys and Girls Club of Capistrano Valley-Insurance Requirements Attached is a certificate of Liability Insurance and Certificate of Workers' Compensation Insurance. I have contacted the insurance agent directly and she will be including the Capistrano Unified School District on the policy and will be sending us the endorsement form.' I am requesting that we take the Boys and Girls Club off the non-pay list, since I anticipate the proper certificates within the next few days. Thank you! 49 KC . ORRR) CERTIFICATE Or INSURANCE - ISSUE DATE IMM/DD/YY) 5/20/97 ,ODUCERTHIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS Markel Insurance Company (ZECc-�\I"D NO IGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, 1� P.O. Box 3870 3 34 P t>"J ND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Glen Allen, VA 23058-3870�p( 11 COMPANIES AFFORDING COVERAGE COMPANY CODE SUB-CODE LETTER A MARKEL INSURANCE COMPANY C. '&1 COMPANY INSURED B LETTER Boys&Girls Club of Capistrano Valley COMPANY C 31371 EI Camino Real LETTER San Juan Capistrano, CA 92675 COMPANY D LETTER COMPANY E LETTER 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 AM. 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 O POLICY EFFECTIVE POLICY EXPIRATION TR TYPE OF INSURANCE POLICY NUMBER DATE IMM/DD/YY) DATE(MM/DD/YY) LIMITS A GENERAL LIABILITY GENERAL AGGREGATE $ 3,000,000 X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OPS AGGREGATE 5 1,000,000 CLAIMS MADE M OCCUR. 8502CY009485-2 11-01-1996 11-01-1997 PERSONAL&ADVERTISING INJURY $ 1,000,000 OWNERS&CONTRACTOR'S PROT. EACH OCCURRENCE $ 1,000,000 FIRE DAMAGE(Any one fire) s 100,000 MEDICAL EXPENSE(Any one person) $ 5,000 AUTOMOBILE LIABIUTY COMBINED SINGLE $ ANY AUTO LIMIT ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per Person) a HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Peraccitlent) 8 GARAGE LIABILITY PROPERTY DAMAGE S EXCESS LIABILITY EACH OCCURRENCE a UMBRELLA FORM AGGREGATE 5 OTHER THAN UMBRELLA FORM STATUTORY LIMITS WORKER'S COMPENSATION EACH ACCIDENT 5 - AND EMPLOYERS'LIABILITY DISEASE-POLICY LIMIT Is DISEASE-EACH EMPLOYEE 8 A OTHER Property I 8502CY009485-2 11-01-1996 1 11-01-1997 DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS Certificate holder is included as additional insured as lessor of premises. CERTIFICATE HOLDER 'CANCELLATION - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO City of San Juan Capistrano MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION 32400 Paso A Delano OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR San Juan Capistrano, CA 92675 REPRESENTATIVES. - AUTHORIZED REPRESENTATIVE Bruce A. Kay VPO ACORD.25-S(7/90) (c) ACORD CORPORATION 1990. f t p_�♦- nc�t j ' 4 1 r fi r > > t t 1' J _ t fr t to (� ., Q�•r•� •��yli''ywa�� } I T 'S _a, If/Y L ''11, ` '-• - P.O•BV/V�'► �' r"T:`l,. A�w�1 ,�'�• �o♦T.I�f.�/VV��'iJ S-�•. t. S r tl;r d t Zir. - - , y . ,1' . 1. M / f� rf Y7, r' ��T^v �• iVIP�. 4ATLON i • } I 11. r I. rr i i,+• ,`{{/ `j'j`. �I 1 _ - r. :N 1 - 4*1 j T.✓t' T •'"' ti•, J-r 1 ' ~ � �-.,Y, id t Rar ?j• i, ' day '.r 11. r•-f,: :'tr. �, ,,y.• ♦ rly` •. -_' y ry 9.,'•• A Irr Co ERTIFI A1'E OF 1N RKE ':1. NI��.1{{ 8. t. :i� A ., �I,-�f� w` �3 `.-. 1� ftBR ;3, '199 r � :;� <�. ;r �yy�( }� A... Z-' e s PIVYMbt;�i>{�� TIV 2L-.ize� ,;` .. .c t` ',^+ sir ��h / ^t I. Z1�4+,a ' f _ �./Ct7 11:'1�/1/'ti yC./�� i r•t ;t z �.j -�•L r a' 'r 2 < r 1 a '♦ {:S INS. r.G r . v ?l 14 !.S P). i J S f ":4r. t .✓ r ,+ 'r 'f i ; ii.. a? . � s�t ;.I,.4' �.i,�•. �. ♦i•.1(, 4 Vii, f �a 2 .•,L Z > a.f .'t•� t, . ., t ,. C�(r'I'Y�� - A# ' 7 I tI ,, , : . r..♦ .- .,` F."-.-:-#- ` 111#6 `. - _I: .Z'i. ,:7r <, .:: :ilr 1.•`: v.f.t,•. •i• .,I.• • .•tii:;. :� E. r..f4.. 1. \. �.y,.v'> �,, yb .. xv a' q�'ik', �'>fl.;. T...,ry -'p H"a CSP: .,:: .�nJ ,A 9 #t7 s :4 � j( ti P��y`� Er:L �, ., ► f. ;L: -.5..' dS� ,'.% r ,.�: 1.1,}* :/. :^Asp 7��7 1 >Ti).'.i^ "!`t -•rl...' �a4.. 4r4. R F , 1. ,t: r - 1 -L...:: ._ `t. a ?"5 L o _ ,. Z'�:l•r~' `LAS } ;1'2 r'!�. �.``,�.,• ♦� .�'. P •'• ,.a f ra! . f '( 1..j. .Y '_r-'w.F ra :'! Sr! \.`'a`� i _ '.'7'., i.. L Z1. 4 7, �t,t r l •'. '.�•-j ''2 f i 1 f r♦'.� t. �.1'r •�l .l�;�r!"•�•- ' r.?} w�� ♦i.i_�_`'.j� ,r:`,'�l': z. _f Llt• �. ff: •' . r - ii. '.- rSx'1 '-r' .,i: -1 '� .ife' '�...' •;i .. 1,1�.. -�J`. f �; r • _ -5 �.'fY''t•. _ �. t SS• 5� ' <_ ' t: r`;furr r__ {r L �+ .. r1"r.". ea•.t.< ♦2 L--T� r:i ti .'- ti,1 -. -r,.:i;:.` �f - t •t�i y•h•'vfl.r g'. i'i' `EI]r i i .`vf.'�.V_c�,'r2rlri� .< .f•1✓r%� l`�.. i.' �-. 1q{r t•�.'•r ,�I►' 1��. 4 .•.. .. �I .t'•. i; t::�L•'I l•"cf�id,"' :;i` ,� 4 .�., r' .7._7r ,,rj��l{1e. .r Y' - t e.� ;�ty,�, '.t, ''••rJ'` .'r •+_��^ �<: f' •c t p:C;","i 1,' " .' '� , 1. .rrr ��_, • M 4~ '}1 , i•r•T a 1Ct.. `'L�'r ii -�. �r R..t'r�v .j.{: f .i. at _ a..' M•c ,� �• +r ii. }�. .t ♦; .Xr. l..�'- ;1.�-I+it w:I \•�.-f- .•f• < ,.,L?`" la `h�a`. i1iYilbn�y the Funde t u e � vc., ,v 'rl t%a: �: " ,; ,a - .;4 �r. .wi• r }}��1 I f•" j. rI r -�'•„ _ 1 t \ r ., i " ..� aS > •,rf ):... <`. .,, 1 •\I S,� — - �rS�_�"t _ 1 a 1.7:.Jra ,'4''t, 1� :y ter.:.' t r t .4�i.. •.! <a J. ra'i,..•,3 -•1�C, wrS• �. Z.\`. :l.v �i'1 -.- -, '�. ';1i�1 i " t r once sho�ld.tllis oliC be csn` ed. to t,.. g i 1bn. r. I I. lil �? � h. P Y Pridr. #s ncrrri ! rat !a;-riC 4`7:fir/'• t err-�t.� .l}Ya+. a,Y•.',*,' ,. y :' r _ ��,,,- ♦.♦.y: �/I j.�.;�;: , -,r�'' ,v� �k -f :;',�""�"•J Y�'�i.', . . .. .. y,. h..t. L,T,,.�1 .Y►:.I, �, ►�►�fr 1 Ir,. • . , ! .a.* i ? - r a t i t •`t:'. IP a•r:4 A. �. ♦ter' .i _ r t ✓ �;}'• !1, J i .� -i`. la <<t 'fih t and floes not-arp I i emend:,o r L.9 S e a_ �y_Kc `-�. a '� $ �1- 0011 a _q r , ' 1h Qiit nt,termt,•a� Rd�tton b`aR�t. _t _ �,�I 1. '� _'�. `-, j a ' �'" A rr t��R •1 ' i� 7' ,,��,,,,yp`.. YrM7�7I•�"'..•t�� gy ��yw� {:I f. •1-S. ,itiiF43� �e6 t f�sL�Q } ,ft*j,•r•y 1.r. lw 1. �A r'" t•''! .,a,- 1 - < ,t f J.�T�'� - .• ••s... ..'.>t. 1t'V�•.FI. � .\�� I 1:.J� �r,. :�.da.b: Feu ; '� oneaii :nand °.a su, i t r_ ; :: 1; „ - _f',,, .-I.� ;,. w.:1 I y.��, tom.3•v'`::•'v,.i.f�.�, \' i \ ..i:.\.� S4'.,-<, •n{, �' -.,'� 1. .til:�j 'a .,• •.L-< _,_,*j 2'S�•dc <>•sir' ';P�o.+t: ?R�i1. t r-h t r F r .,.Y'. ;' �Y' i tl...i_ n ':I -;1, Rt".. i• .-u.' ..) r�"�J',.✓,y ?r 4'.... f �.. r.c.'. y t � Q�,.1 .♦ ..` .,r "i'-' ,i.. X► +7tw i•.Z.:� �,>ty.•' va• \ ..-?? r`rf IC L- �+::'1 'aJ C < >:w"< k• .1.f "+,1.. -f_ l t.: •r .% >�. y'+,Y. .M'7 •rF' Pb. jV`�''n 1.4 rYi- T... 1 i, V 1,6 rvi' f! ... 1+ !•! `1, .1 .J w},� r• t ;y• • �+Y 01.11 t } waj'a . ♦..,i. ,!lif �.,f,. rJ �:.?: :. .$1:"... .3 '� ..w.',:""::i:!....:n ,,!•.•t .Z.ya,,: < 'f.'•.t'. 'vriA+(:' :i.:� . f c �:.. �'($•� !. " %Z y -Z%, x•'�•- F.-.t'. }x,\••�"" \f',.t 'r�j i..\u• - �>.J,S..i- v:.M:>k' J'e`t.•{!. �y aZ.".}., p`'�� _ ,i�. {� . r' a ks:�•V Z...,3-j .'!.. •. .�t.l ..Y�. F. }. 1S.S� r" >:•: trra_� "Q.\ .•t 1 1 „?. . r 4. t,;b... iy .�h iw 1 a �}` 1�. .!`,r,,'y,l ar.- r' • • ''777tt��...... '".�' 5 t, >a f ^ ',_ fi r t r. 'li =I • , .. r r. .-. :. 2 f 4 y. f AUTHOf�ZE�REPRES NTATiVE D '` ' 2PRESIE ENT: "- ,Z ,, _r 1. �Y:% ! , EMPL0i. .f -S .LI-J�D% ILrI:�'Y- LIMIT I-:NC.L,.UDF�G DEFENSE `�C&-S, . ,�Q ,2y ` .,P. R .:RACEtf R 1�e. ' 1 _ _ r LI 1'ryr r \ "dc it , , . ; a it. .j �4::: r I� t: �1 ,', EMPLOYER DEC 't 6. i � f . ---J�., - --�-' �,GYS At�� GIRLS LcJ� OF (;APISTRANO VAlLEY "•+ I . 3I 3'11 EL GAMING REAL SA.. J�J,'�t� SAP I5I kF'tNc�, . L_ . �It THIS DOCUMENT HAS : a - • SG coo . 30 STATE P.O. BOX 807, SAN FRANCISCO,CA 94101-0807 I eC LE( e p COMPENSATION INSURANCE FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE POLICY NUMBER: 1381364 - 99 ISSUE DATE: 01-01-99 CERTIFICATE EXPIRES: 01-01-00 CITY OF SAN JUAN CAPISTRANO JOB: 1. TEEN RECREATION BUILDING b SAFETY DEPARTMENT 2. AFTER-SCHOOL RECREAT. 32400 PASEO ADELANTO EMPLOYEES=2 SAN JUAN CAPISTRANO, CA 92675 This is to certify that we have issued a valid Workers' Compensation insurance policy in a from approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the fund except upon 10 days' advance written notice to the employer. We will also give you 10 days' advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies listed herein. notwithstanding any requirement, term, or condition of any contract or other document with respect to which this certificate of insurance 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. 2�L�PR2S IDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: 81,000,000.00 PER OCCURRENCE. O M n W C_, m n N ' 0 co m EMPLOYER LEGAL NAME BOYS AND GIRLS CLUB OF CAPISTRANO BOYS AND GIRLS CLUB OF CAPISTRANO VALLEY VALLEY (A NON-PROFIT PUBLIC BENEFIT CORP) 31371 EL CAMINO REAL, S J CAPISTRANO, CA 92675 PRINTED: 12-18-98 P0408 DOCUMENTTHIS 'MMWMW��. M K41 1 NMZ1� 01 a 11/6/97 M.M, �N .0 Producer THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION MANION/BELL INSURANCE ASSOCIATES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O. BOX 36196 HOLDER.THIS CERTIFICATE DOES NOT AMEND. EXTEND OR LOS ANGELES,CA. 90036 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW (213)387-8294*FAX(213)389-5833 COMPANIES AFFORDING COVERAGES LIC.#0655274 Company Insured A MAPKEL INSURANCE COMPAW Company BOYS AND GIRIS CLUB OF CAPISTRANO VALLEY B rn 31371 EL CAMINO REAL Company FYI-- SAN YUAN CAPISTRANO,CA.92675 C D t 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 POLICY LTR TYPE OF INSURANCE NUMBER INCEPTION EXPIRATION LIMITS A x COMM.DENEpALuaeluTr 9502CY009485-3 11/1/97 11/l/98 GENERAL AGGREGATE $1,000,000 OCCURRENCE POW PRODUCTS*COMP/Olp AGG $3,000,000 OTHER PERSONAL&ADV INJURY $1,000,000 EACH OCCURRENCE $1,000,000 FIRE DAMAGE(Any one fire) $50,000 (EXCLUDING MEMBERS AND STAFF) IMED EXPIAny one person) $5,000 AUTOMOBILE LIABILITY ANYALTO COMBINED SINGLE LIMIT ALL OWNED AUTO$ BODILY INJURY SCHEDULED ALTOS (Per person) HIRED AUTOS BODILY INJURY NON 0W 00 AUTOS (Par accident) PROPERTY DAMAGE EXCESS LIABILITY EACH OCCURRENCE UMBRELLA FORM [AGGREGATE OTHER THAN UMBRELLA FORM ACCIDENT COVERAGE MED LIMIT PRIMARY SICKNESS EXCESS DEDUCTIBLE IDEDUCTIBLE OTHER OTHER DESCRIPTION OF CIPERATIONSIOCATMINOVEHIGUESMPECMI.ITEMS CERTIFICATE HOLDER IS ADDED AS ADDITIONAL INSURED WITH REGARD TO LIABILITY ARISING OUT OF use of premises. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL City of San Juan Capistrano 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, 32400 Paseo Adelanto BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY San Juan Capistrano, CA 92675 OF ANY KIND 2 Up' T' COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZE.FE17.!NTAT 41