1977-0216_C.T. & F, INC_Insurance Certificate• � r��s s
or/d
INSURANCE B R O K E R SL RRC IVFD
February 16, 1977 FEB ( 1 L,11'77
City of San Juan Capistrano
32400 Paseo AdelantoCPI_ i;? i
San Juan Capistrano, Calif.
Attn: Mrs. Hanover
Re: C.T.&F., Inc.
Gentlemen:
You will find enclosed:
❑ Policy as requested.
F1 Endorsement which should be attached to your policy.
E] Renewal policy continuing coverage on same terms and conditions.
❑ Certified copy of policy the original having been sent to the mortgagee.
Loss Payable Endorsement.
Ej Duplicate copy of policy.
® Certificate of Insurance as requested. (Corrected)
Certificate of Insurance with copy of Loss Payable Endorsement,
issued in your favor.
n
Very truly yours,
TRANS WORLD INSURANCE BROKERS
BY: Pat Crispis
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130 EL CAMINO DRIVE / BEVERLY HILLS, CALIFORNIA 90212 / CABLE ADDRESS: TRANSBROK / (219) 878-1100
CERO'ICATE OF INSURSPCE
'Certificate Holder:
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CITY OF SAN JUAN CAPISTRANO
32400 PASEO ADELANTO
SAN JUAN CAPISTRANO, CALIFORNIA
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NAME OF INSURED: C. T. & F., INC.
Date: February 16, 1977
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THIS CERTIFIES THAT THE INSUREDS NAMED ABOVE ARE INSURED FOR:
1. COMPREHENSIVE GENERAL AND AUTOMOBILE LIABILITY: All Operations, covering the liability Imposed by law or
assumed under contract for Personal Injury to persons or Damage to Property of others.
COMPANY AND POLICY NUMBER TERM LIMIT
ADMIRAL INSURANCE COMPANY 8-6-76 $300,000 Combined Single
#6CG1846 to Limit Bodily Injury and
8-6-77 Property Damage
II. STATUTORY WORKMEN'S COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE:
All California operations and all states endorsement.
COMPANY AND POLICY NUMBER
III. OTHER INSURANCE AS SHOWN BELOW:
MAINE BONDING & CASUALTY CO.
#003541
TERM EMPLOYERS' LIABILITY LIMIT
10-25-76 $700,000 Excess of
to Primary Limit
10-25-77
IV. SPECIAL PROVISIONS PERTAINING TO THIS CERTIFICATE:
INSTALLATION OF TRAFFIC SIGNAL AT THE INTERSECTION OF:
DEL OBISPO ST. AND BLUE FIN DR.
IT IS UNDERSTOOD AND AGREED THAT THE CERTIFICATE HOLDER IS INCLUDED
AS AN "ADDITIONAL INSURED" BUT ONLY AS RESPECTS THE OPERATIONS OF
THE NAMED INSURED IN RESPECTS TO WORK PERFORMED FOR THE CITY.
In the event the above policies should be cancelled, assigned or the amount of coverage reduced during the policy term, the
undersigned will give THIRTY (30) days' written notice to the above name holder of this CERTIFICATE by registered mail.
This certificate of insurance neither affirmatively nor negatively amends, extends or alters the coverage afforded by Policy
Numbers shown hereon issued by Companies shown hereon.
By: &WIZ6
,e
se �.
INSURANCE SROKER5
130 EL CAMINO DRIVE
BEVERLY HILLS, CALIFORNIA 90212
(213) 878-1100
FORM C-100 TW REV 7-7a
TRUCK INSURANCE EXCHANGE
INTW CERTIFICATE OF INSURANCE
,When countersigned by an authorized represel�Ive of the Company, this certificate supersedes anovlously issued certificates and certifies
that the following policy(ies) have been issued to the insured for the coverage indicated. This certificate Is subject to all of the terms, con-
ditions and limitations set forth in the described policy(ies) and endorsements thereto. it is furnished as a matter of information only and does
not change, modify or extend the policy(ies) in any way.
Named
Insured . C T & F INC.
Address , 6853 LIVE OAK STREET
BELL GARDENS, CA. 90201
Policy No -Workmen' s
29 67 307 9372 ��'19etien
Agent Policy No. -Other C.v.
UNLESS REPLACED BY THE COMPANY'S STANDARD CERTIFICATE OR UNLESS CANCELLED, THIS INTERIM CERTIFICATE
SHALL BE EFFECTIVE FOR A PERIOD OF THIRTY DAYS COMMENCING 4:00 P M 2/16 19 77
K 4 Agent: Check here if a permanent certificate is to be issued by the Policywrjting Office.
*Includes Goods or Products Warranty, Written Lease of Premises, Easement Agreement, Municipal Or-
dinance Agreement, Sidetrack Agreement, Elevator or Escalator Maintenance Agreement only, unless ac-
companied by specific endorsement providing additional Contractual Coverage.
DescribedX Des
below Wei
OWNED
AUTO-
MOBILES
IF
It is hereby agreed that upon cancellation or terminbtion
of this policy or policies from any cause the Company
will mall q0 days notice in
writing thereof to the other interest shown below.
Other
CITY OF SAN JUAN CAPASTRANO
32400 PASEO ADELANITO
SAN JUAN CAPASTRANO, CA.92675
ATTN: CITY CLERK
.. Not Apr, cable in Texas.
... Ap-'icable in Texas only.
56-05164-761251 PRiVrea IN US A. VL
LAST 3
DIGITS
SHOWN
In the event of any material change in or cancellation of said policies,
the Company will make every *Kort to notify the party to whom this
certificate is issued of such change or cancellation, but the Company
undertakes no responsibility by reason of any failure so to do.
TRUCK INSURANCE EXCHANGE
Truck Underwrit4s Association, Atty. in fact
President
*
is
COVERAGE
LI
ITS LIABILITY
COVERED
NOT AUTO LIABILITY
COVERED
_7
®
❑
Owned & HIRED•
Bodily Injury $
,000 each ppcson
❑
®
Hired
$
,000 each occurrence
Non -Owned
Properly Damage $
,000 edch oEcurrence
❑
®
Employer's Non -Ownership
Contingent Liability
GENERAL LIABILITY
Bodily Injury $-
T,000Adchp6Yson**
M&C-OLT
$
occurrence
❑
®�
Owners 8 Contractors
$
,000wch
Contractual *
,000aggregate products
Elevators
Property Damage $
.000 each occurrence
❑
X
Products
$
,000 aggregate products
owners 8 contractors protective **
-contractual***-completedoperations A,*
Single Limit
Liability
for Coverages checked ®above
$_-300_000 aggregate products
$
NIL ,000 each occurrence
❑
®
CARGO
$
,000 each vehicle
$
,000 each occurrence
Less $
Deductible
❑
U
WORKMEN S
COMPENSATION
Statutory
*Includes Goods or Products Warranty, Written Lease of Premises, Easement Agreement, Municipal Or-
dinance Agreement, Sidetrack Agreement, Elevator or Escalator Maintenance Agreement only, unless ac-
companied by specific endorsement providing additional Contractual Coverage.
DescribedX Des
below Wei
OWNED
AUTO-
MOBILES
IF
It is hereby agreed that upon cancellation or terminbtion
of this policy or policies from any cause the Company
will mall q0 days notice in
writing thereof to the other interest shown below.
Other
CITY OF SAN JUAN CAPASTRANO
32400 PASEO ADELANITO
SAN JUAN CAPASTRANO, CA.92675
ATTN: CITY CLERK
.. Not Apr, cable in Texas.
... Ap-'icable in Texas only.
56-05164-761251 PRiVrea IN US A. VL
LAST 3
DIGITS
SHOWN
In the event of any material change in or cancellation of said policies,
the Company will make every *Kort to notify the party to whom this
certificate is issued of such change or cancellation, but the Company
undertakes no responsibility by reason of any failure so to do.
TRUCK INSURANCE EXCHANGE
Truck Underwrit4s Association, Atty. in fact
President
*
is
Primary CERTIFICATE OF INSURANCO
® (Insnraace) The Exchange or Company designated on the reverse side as number 2
Excess
❑ Insurance) Excess over Primary with Company designated on reverse side as letter
When countersigned by an authorized representative of the Company, this certificate supersedes any previously issued certificates and certifies
that the following policy(ies) have been issued to the Insured for the coverage indicated. This certificate is subject to all of the terms, condi-
tions and limitations set forth in the described policy(ies) and endorsements thereto. It is furnished as a matter of information only and does
not change, modify or extend the policy(ies) in any way.
Named
Insured C T fr F INC.
Address . 6853 LIVE OAK STREET
BELL GARDENS, CA 90201
Effective from: 2-16-77
To:
LIMIT(S)
INCLUDE(S)
BOTH PRIMARY
AND EXCESS
(if excess
applicable)
OWNED
AUTO-
MOBILES,
IF
COVERED
Excess Policy or Certificate Number
29 6-7 307 9372 34 58C
Agent I Policy Number
at which time this certificate becomes void ® or until cancelled if this box
*Includes Goods or Products Warranty, Written Lease of Premises, Easement Agreement, Municipal Or-
dinance Agreement, Sidetrack Agreement, Elevator or Escalator Maintenance Agreement only, unless ac-
companied by specific endorsement providing additional Contractual Coverage.
i YEAR, MAKE, TYPE OF BODY, LOAD CAPACITY I IDENTIFICATION NUMBER
POLICY NUMBER Umbrella Liability
It is hereby agreed that upon cancellation or termination
of this policy or policies from any cause the Company
will mall THIRTY ( 3 0 ) days notice in
writing thereof to the other Interest shown below.
Other CITY OF SAN JUAN CAPISTRANO
Interest 32400 PASEO ADELANITO
SAN JUAN CAPISTRANO, CA 92675
ATTN: CITY CLERK
**Not applicable in Texas
***Applicable in Texas only
56-01877-761281 PRINTED IN NSA. Qr 1
LAST 3
DIGITS
SHOWN
$ ,000 retained limit
$ each occurrence
$ aggregate
(OKLAHOMA CERTIFICATE)
In the event of any material change in or cancellation of said policies,
the Company will make every effort to notify the party to whom this
certificate is issued of such change or cancellation, but the Company
undertakes no responsibility by reason of any failure so to do.
Notice of cancellation of the primary coverage outomoti-
Cully terminates excess coverage. A breakdown of the
_primary limits and the excess limits will be provided up-
on dhiraand.
t
Countersigned
y-
' Amhorize p rive
COVERAGE
COMBINED LIMITS OF LIABILITY
COVERED
NOT
COVERED
AUTO LIABILITY
®
❑
Owned 8 HIRED
Bodily Injury $
,000 each person
❑
®
KXbEDC M Non -Owned
$
,000 each occurrence
❑
®
Employer's Non -Ownership
Property Damage $
,000 each occurrence
Contingent Liability
GENERAL LIABILITY
Bodily Injury $
,000 each persons#
M&C - OLT
$
,000 each occurrence
❑
®
Owners 8 Contractors
Contractual*
$
,000.oggregate products
Elevators
Property Damage $
,000 etch occurrence
❑
®
Products and/or
$
,000 aggregate products-
Completed Operations
owners 8 contractors,protective**s
,
—contractual***—and/or completed. operationsill
$
300 ,000eachloccurrence
Single Limit
Liability for Coverages checked ® above
$
N I L " .,000 aggrwggate products
v
❑
®
CARGO
$
,00 each vehicle
$
,64 each occurrence
U
LJ
WORKMEN'S COMPENSATION
Statutory
*Includes Goods or Products Warranty, Written Lease of Premises, Easement Agreement, Municipal Or-
dinance Agreement, Sidetrack Agreement, Elevator or Escalator Maintenance Agreement only, unless ac-
companied by specific endorsement providing additional Contractual Coverage.
i YEAR, MAKE, TYPE OF BODY, LOAD CAPACITY I IDENTIFICATION NUMBER
POLICY NUMBER Umbrella Liability
It is hereby agreed that upon cancellation or termination
of this policy or policies from any cause the Company
will mall THIRTY ( 3 0 ) days notice in
writing thereof to the other Interest shown below.
Other CITY OF SAN JUAN CAPISTRANO
Interest 32400 PASEO ADELANITO
SAN JUAN CAPISTRANO, CA 92675
ATTN: CITY CLERK
**Not applicable in Texas
***Applicable in Texas only
56-01877-761281 PRINTED IN NSA. Qr 1
LAST 3
DIGITS
SHOWN
$ ,000 retained limit
$ each occurrence
$ aggregate
(OKLAHOMA CERTIFICATE)
In the event of any material change in or cancellation of said policies,
the Company will make every effort to notify the party to whom this
certificate is issued of such change or cancellation, but the Company
undertakes no responsibility by reason of any failure so to do.
Notice of cancellation of the primary coverage outomoti-
Cully terminates excess coverage. A breakdown of the
_primary limits and the excess limits will be provided up-
on dhiraand.
t
Countersigned
y-
' Amhorize p rive