04-1028_BOYS & GIRLS CLUBS OF CAPISTRANO VALLEY_Insurance CertificateACOr?Q,M 'CERTIFICAT F LIABILITY INSURN
ioiziz aa'
PRODUCER (949)852-0909 FAX (9 52-1131
Milestone Insurance Brokers
P.O. Box 19598
8 Corporate Park, Ste 130
Irvine, CA 92623-9598
THIS CERTIFICATE IS NFED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC#
INSURED Boys &Girls Clubs of Capistrano Valley
One Via POsitiva
San Juan Capistrano, CA 92675
INSUREgA Philadelphia Indemnity Ins.
INSURER B:
INSURER C:
NSURER D:
INSURER E:
OV RA ES
LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTW ITHSTANDINi
THE POLICIES OF INSURANCE
OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
ANY REQUIREMENT, TERM
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
MAY PERTAIN,
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
DD'
TYPE OF INSURANCE
POLICY NUMBEfl
POLICY EFFECTIVE
DATE (mwnntyy)
POLICY EXPIRATION
LIMBS
San Juan Capistrano, CA 92675
GENERAL LIABILITY
PHPK098729
11/01/2004
11/01/2005
EACH OCCURRENCE $ 1,000,00
DAMAGE TO RENTED $ 100,00C
X COMMERCIAL Or LIABILITY
CLAIMS MADE � OCCUR
MED EXP (My one Person) $ 5,00C
PERSONAL 8 ADV INJURY $ 1,000,00(
A
GENERAL AGGREGATE $ 3,000,00
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP ADD $ 1,000,00
POLICY JEPRCTO LOC
AUTOMOBILE
LIABILITY
PHPK098729
11/01/2004
11/01/2005
COMBINED SINGLE LIMIT $
(Es accident) 1,000,00(
X
ANY AUTO
BODILY INJURY $
ALL OWNED AUTOS
(Per person)
SCHEDULED AUTOS
A
HIRED AUTOS
BODILY INJURY $
(Per accident)
NON -OWNED AUTOS
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
OTHER THAN EA ACC $
ANY AUTO
AUTO ONLY: AGO $
EXCESS/UMSRELLALIABILITY
PHUB037454
11/01/2004
11/01/2005
EACH OCCURRENCE $ 1,000,00
AGGREGATE $ 11000,00
X OCCUR CLAIMS MADE
$
A
$
DEDUCTIBLE
$
RETENTION $
WCSTATU- I JOTHPR
WORKERS COMPENSATION AND
1MITq
E.L. EACH ACCIDENT $
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
-OFFICER/MEMBER EXCLUDED?
E.L. DISEASE - EA EMPLOYE $
E.L. DISEASE- POLICY LIMIT $
If yes, describe under
SPECIAL PROVISIONS below
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
are added as additional insured as
ity of San Juan Capistrano, its officers, agents and employees
respects the operations of the Named Insured.
Except 10 days notice for non-payment of premium.
rAMCPI 1 AnnM
Ir
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30° DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
City of San Juan Capistrano
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
32400 Paso Adelanto
OF ANY KIND PON THE INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORQEDREP SENTATIV A
X✓ l al
San Juan Capistrano, CA 92675
i
ACORD 25 (2001/08) ®ACORD CORPORA TI N 1988
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or after the coverage afforded by the policies listed thereon.
ACORD 25 (2001/08)
a4CCRO . CERTIFICAT F LIABILITY INSURAN O
BOYPS &- ID 9B
DATE( 05/06/05 )
0
PRODUCER
Chapman & Associates
License #0522024
P. O. Box 5455
THIS CERTIFICATE IS ED AS A MATTER OF INFORMATION
ONLY AND CONFERS N RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
NSR
Pasadena CA 91117-0455
Phone: 626-405-8031 Fax: 626-405-0585
INSURERS AFFORDING COVERAGE NAIC #
INSURED
INSURER A: Alen North America Ins CO
INSURER B.
REPRESENTATIVES.
Boys&Girls Club Of Capistrano
Valley
Via Positiva
San Juan Capistrano CA 92675
INSURER C.
INSURER D.
INSURER E.
—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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR
NSR
TYPE OF INSURANCE
POLICY NUMBER
DATIEYMMIDD/Yl'
EXPIRATION
POATE(MM/DEI )
LIMITS
Linda Evans
REPRESENTATIVES.
GENERAL LIABILITY
Aur DREPRE
San Juan Capitrano CA 92675
EACH OCCURRENCE $
PREMISES (Ea occurence) S
COMMERCIAL GENERAL LIABILITY
MED EXP (Anyone person) $
CLAIMS MADE 11 OCCUR
PERSONAL& ADV INJURY $
GENERALAGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER.
PRODUCTS - COMPIOP AGG $
PRJECT O- LOC
POLICY
AUTOMOBILE
LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT $
(Ea accident)
BODILY INJURY $
(Per person)
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY $
(Per accident)
HIRED AUTOS
NON -OWNED AUTOS
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
OTHER THAN EA ACC $
ANY AUTO
AUTO ONLY: AGO $
EXCESSIUMBRELLA LIABILITY
EACH OCCURRENCE $
AGGREGATE $
OCCUR 1-7 CLAIMS MADE
$
DEDUCTIBLE
$
RETENTION $
WORKERS COMPENSATION AND
TORY LIMITS I I ER
E.L. EACH ACCIDENT $1000000
A
EMPLOYERS'LIABILITY
ANY PROPRIE1 OR/PARI NNUEXECUTIVE
OFFICERIMEMBER EXCLUDED?
WC1003364
01/01/05
01/01/06
E.L. DISEASE - EA EMPLOYEE $ 10000 06
E.L. DISEASE -POLICY LIMIT $1000000
It yes, describe under
SPECIAL PROVISIONS below
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
*******CERTIFICATE OF INSURANCE IS ISSUED AS EVIDENCE OF COVERAGE ONLY******
_
__ CANCELLATION
CER I IFRCA I E nvwr=l
CITYSAN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
City of San Juan Capistrano
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
City Clerk r B Office
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
Linda Evans
REPRESENTATIVES.
32400 Paseo Adelanto
Aur DREPRE
San Juan Capitrano CA 92675
l.1 ArnCn rnGono ATlnrl 1000
ACORD 25 (2001/08)