1977-0202_CROSBY COMPANY, T.J._Insurance Certificate r
®® CERTIFICATE OF INSURANCE
Issued to: Named Insured and Address:
City of San Juan Capistrano, T,J, Crosby dba: T.J. Crosby Co. ,
32400 Paseo Adelanto and Tim Crosby, Individual
San Juan Capistrano, California P.O. Box '#16489
92675 Irvine, California 92713
We hereby certify that the following described insurance is in force at this date with:
Midland Insurance Company
THIS CERTIFICATE OF INSURANCE NEITHER AFFIRMATIVELY NOR NEGATIVELY
AMENDS,EXTENDS, OR ALTERS THE COVERAGE AFFORDED BY THE POLICY OR POLI-
CIES INDICATED IN THIS CERTIFICATE.
LOCATION OF RISK:
TYPE OF INSURANCE: Umbrella Liability
POLICY OR CERTIFICATE NO.: # UL 389247
PERIOD: From March 6, 1976 To March 6, 1977
LIMITS OF LIABILITY: Difference between primary* and $1,500,000. CSL
*General Liability $500,000. Each Occurrence/$500,000. Aggregate Bodily Injury
$100,000. Each Occurrence/$100,000. Aggregate Property Damage
Auto Liability $250,000. Each Person /$500,000. Each Occurrence Bodily Inj .
$100,000. Each Occurrence Property Damage
Should the above mentioned contract of insurance be cancelled during the above named policy period,
we, the Undersigned, will endeavor to give 10 days written notice to the holder of this document,
but failure to give such notice shall impose no obligation of any kind upon the Undersigned or upon
the Companies.
WORLDWIDE FACILITIES, INC.
Dated_February2 , 147 7 cglk�rr I3y
W b
Additional Insured Endorsement naming City of San Juan Capistrano
as Additional Insured request in compliance with requirement with
the City of San Juan Capistrano to be handled under separate cover
and forthcoming within estimated fourteen (14) days.
' • ENDORSEMENT
e Effective Date
is aewaidratiaa of tis yrawim 4wmedo it la &Octad the
talloviwt sattiftl is bedw rwwad as an additiawal lbewad
radar tilt Bona!& ** may as raapaet tis "NWA "s at
Wo Jawad bawedr
!moi 4Wkb Ess agar IXVW0WW0W is of st>easts and
aiirw im in ftm irow empl twat aiti Wo laa/ii at fobs
.jab being lib awUaMr dae is 00MUast oawt #3 ol".00
]Et to ftdbar atn I Yb .*=drag obs abwe **tiff as as
atdditiaaal iwwsad MAU tot OWN* to Ines&&* tis
0WWWW'a lidta of lialdlitr as apadtiad M on
dasiaeatUM at this palloy.
Effective MUM 12:01 AM Standard Time, this Endorsement No. �
attached to and made a rt of Policy No. S7 of MIDLAND INSURANCE COMPANY
issued to • r*% �'o Cb..
(The information above is required only when this endorsement is issued subsequent to preparation of the policy.)
Nothing herein contained shall be held to vary, alter, waive or extend any of the terms, conditions, agreements or limitations
of this policy other than as above stated.
is
_ t
.................... .. ...
1. e ..... .... ................... . ...... ........ .... .... .....
Karl E. lo.�rf jSacretarr lames P. Craig, Praudient
By
GCSA-%A-rrrs�/t-�"1� 2/477 at
Auth,vris.d Represao tat ive
FORM UND.NO.262 (4/]61 laM EXTRA COPY,
REPLACES UND.NO.45
ENDORSEMENT
s
Effective Date 7/31/77
In consideration of the premium charged, it is agreed the
following entity is herby named as an additional Insured
larder this policy, bgt only as respect the operations of
the Named Insureds
Specified as Job for major improvements of streets and
sidewalks in San Juan Capistrano with the length of the
job being 120 calander days in contract cost $31,148.00
It is further agreed thatnaming the above entity as an
additional insured shall not serve to increase the
Company's limits of liability as specified on the
declarations of this policy.
Effective 1/31/77 12:01 AM Standard Time, this Endorsement No. 10
attached to and made a part of Policy No. n7'.389247 of MIDLAND INSURANCE COMPANY
issued to T. J Crosby Co
(The information above is required only when this endorsement is issued subsequent to preparation of the policy.)
Nothing herein contained shall be held to vary, alter, waive or extend any of the terms, conditions, agreements or limitations
of this policy other than as above stated.
............` . .�. .. ......
Karl L Dierr, Seaelary �y Jamas P. Gm 9, Presrdsm
By b'�i�-� 4,4 . /[ z 2/4/77 ak
Avrhal:ed Represan move
FORM UND.NO.262 (4/76) 10M PRODUCI;:'S COPY
nrr, nrFc ¢gyp. NO. 45
Allen Jayne Insurance, Inc.
1833 W. Olympic Blv
Los Angeles, CA 900M /� .
�AMM� (feral cafe ol 4. njurance
INSURANCE COMPANIES
G=Great American Insurance Company A=American National Fire Insurance Company
AG=Agricultural Insurance Company (Herein called the Company) AA=American Alliance Insurance Company
In the event of concelation of the policies designated beIow,X Kthe Company 06 mail 10 days prior notice
thereof to:
NOTE: This Certificate of Insurance neither
City of San Juan Capistrano
.32400 Paseo Adelanto affirmatively nor negatively amends, extends,
San Juan Capistrano+ CA 92675 nor alters the coverage afforded by the
policy or policies numbered in this certi-
L _J ficote.
The Company(ies) as designated below certify that the following insurance policies have been issued to:
NAME OFINSURED ADDRESS OF INSURED
T.J. Crosby IBA: T.J. CROSBY CO. P. 0. Box 16489, Irvine, CA 92713
o TYPE OF INSURANCE POLICY NUMBER POLICY PERIOD LIMITS OF LIABILITY
BODILY INJURY PROPERTY DAMAGE
WORKMEN'S COMPENSATION PC 8952637 9-29-76 STATUTORY NO COVERAGE
and EMPLOYERS' LIABILITY 9-29-77 $ 100 000. NO COVERAGE
COMPREHENSIVE EACH
GENERAL LIABILITY $ OCCURRENCE $ OCCURRENCE
$ AGGREGATE $ AGGREGATE
MANUFACTURERS'AND $ OACH
CCURRENCE
CONTRACTORS' LIABILITY $ OCA CCURRENCE $ AGGREGATE
OWNERS' AND CONTRACTOR
$ EACH
OCCURRENCE
PROTECTIVE LIABILITY $ DACH $ AGGREGATE
OWNERS' LANDLORDS AND
TENANTS' LIABILITY $ OACH EACH
CCURRENCE $ OCCURRENCE
COMPLETED OPERATIONS
AND $ EACH EACH
OCCURRENCE $ OCCURRENCE
PRODUCTS LIABILITY $ AGGREGATE $ AGGREGATE
COMPREHENSIVE $ EACH PERSON
AUTOMOBILE LIABILITY $ EACH EACH
OCCURRENCE $ OCCURRENCE
EACH PERSON
OWNED AUTOS $ OEACH CCURRENCE $ OEACH
CCURRENCE
O~ $ EACH PERSON
QQ HIRED AUTOS $ OEACH EACH
CCURRENCE $ OCCURRENCE
OTHER NON-OWNED $ EACH PERSON
AUTOS $ OCCURRENCE $ EACH
OCCURRENCE
COMMERCIAL UMBRELLA $ each Occurrence, aggregate where
LIABILITY applicable, in excess of Primary insurance recorded.
0
DESCRIPTION AND LOCATION OF OPERATIONS AND AUTOMOBILES COVERED
JOBr Major Improvements of Streets and Sidewalks in San Juan
Capistrano.
This Certificate is not valid unless countersigned by an authorized representative of the Company./�� Qy/I/�•�''��
February?, 1977 mt "`A�RIZEO flEP� SENTAT E
F.40021&7f76 ORIGINAL
Allen Jayne Insurance, Inc.
1833 We Olympic Div
L �
41 oa Angeles. CA 90
AROERWM eputicate o/ k4urance
JLINSURANCE COMPANIES
G=Great American Insurance Company A=American National Fire Insurance Company
AG_`�M Instr,�Ce n„0., (Herein called the Company) Ak •�v =tom Cama
Will
In the event of cancelation of the policies designated below, The Company mail 10 days prior notice
thereof to:
r � NOTE: This Certificate of Insurance neither
City of Sen Joan capLattgoD
32400 yeile* Adelanto affirmatively nor negatively amends, extends,
nor alters the coverage afforded by the
Soo JUsn Capistromo, CIA 92675
policy or policies numbered in this terti-
L_ _J ficate.
The Company(ies) as designated below certify that the following insurance policies have been issued to:
NAME OFINSURED ADDRESS OF INSURED
T.J. Crosby ESAo T.J. CXMW CO. !. O. ftn 16499, IrvifM. CA 92713
o TYPE OF INSURANCE POLICY NUMBER POLICY PERIOD LIMITS OF LIABILITY
BODILY INJURY PROPERTY DAMAGE
WORKMEN'S COMPENSATION STATUTORY NO COVERAGE
and EMPLOYERS' LIABILITY 9,29.77 $ NO COVERAGE
COMPREHENSIVE EA E CH
GENERAL LIABILITY $ OCCURRENCE $ OCCURRENCE
$ AGGREGATE $$R AGGREGATE
MANUFACTURERS'AND OCCURRENCE
CONTRACTORS' LIABILITY $ OEACH
C OCCURRENCE AGGREGATE
OWNERS'AND CONTRACTORpp $ EACH
$
PROTECTIVE LIABILITY OCCURRENCE $ AGGREGATE
OWNERS' LANDLORDS AND
TENANTS' LIABILITY R W EAC oCCuRRENCE $ OEACH
CCURRENCE
COMPLETED OPERATIONS R
AND OCCUREACH
RENCE $ OCCURRENCE
PRODUCTS LIABILITY $ AGGREGATE $ AGGREGATE
COMPREHENSIVE $$ EACH PERSON
AUTOMOBILE LIABILITY 2 OCCURRENCE OEACH
CCURRENCE
$ EACH PERSON
OWNED AUTOS $ EACH OCCURRENCE $ EACH
OCCURRENCE
O~ $ EACH PERSON p
QQ HIRED AUTOS $ OCCURRENCE $ OEACH
CCURRENCE
J OTHER NON-OWNED $$ EACH PERSON 2
AUTOS OEACH
CCURRENCE
S OCCURRENCE
COMMERCIAL UMBRELLA $ each occurrence, aggregate where
LIABILITY applicable, in excess of Primary insurance recorded.
0
DESCRIPTION AND LOCATION OF OPERATIONS AND AUTOMOBILES COVERED
Jane Nsjor Itrprovaysats of Streets and 314swlal s is Sao Joon
Capistrano.
This Certificate is not valid unless countersigned by an authorized representative of the Company.
AUTHORIZED REPRES TATIV
F./0021 A—8-T5
Allen Jayn a Ins. Inc.
1833 W. Olympic Blvd tweLL gl CPBWFor
Los Angeles, CA 90006
CERTIFICATE OF INSIIRANCE
• The City of San Juan Capistrano
32400 Paseo Adelanto
San Juan Capistrano, CA 92675
THIS IS TO CERTIFY as to the existence of insurance,as of the date of execution hereof,with Harbor Insurance-Company,
as described below:
Name of Insured: T. J. Crosby .DBA* . T. J. CROSBY CO. , ETAL
Address of Insured: P. 0. Box 16489, Irvine, CA 92713
Location of Risk: Major Improvements of Streets and Sidewalks in San Juan
Capistrano
Kind of Insurance: Comprehensive General Liability
Policy No. 125940 period from 10-15-76 to 10-15-77
Limits: Bodily Injury each person $ 500,000.
each accident $ 500,000. aggregate $ 500,000.
Property Damage—each accident $ 100,000. aggregate $ 100,000.
Kind of Insurance: Comprehensive Automobile Liability
Policy No. 125940 period from 10-15-76 to 10-15-77
Limits: Bodily Injury each person $ 250,000.
each accident $ 500,000. aggregate $ 500,000.
Property Damage each accident ' $ 100,00o. aggregate $ 100,000.
Kind of Insurance:
Policy No. period from to
Limits:
It is hereby understood and agreed that the certificate holder will be given ten (10) days written notice before any reduction of coverage or
cancellation of this insurance is effective.
This.Certificate of Insurance is issued as a matter of information only and does not in any way amend, alter or vary the coverage afforded by the
policy or policies referred to herein and such policy or policies are subject to endorsement,alteration,transfer,assignment and cancellation according
to the terms,conditions and provisions of such policy or policies.
Dated at Los Angeles, California this 2nd day of February, 1977
ET RAWFORD
p
(SEE OVER)
CX C.CS�^U BY
m{ _m Jayne Insu nc , Inc. mt
ENDORSEMENT
IT IS UNDERSTOOD AND AGREED THAT THE CITY OF SAN JUAN CBPISTRANO IS (ARE)
NAMED HEREWITH AS AN ADDITIONAL INSURED UNDER THE POLICY BUT ONLY IN
CONNECTION WITH CONSTRUCTION BY T. J. CROSBY CO. OF MAJOR IMPROVEMENTS OF
STREETS AND SIDEWALKS IN SAN JUAN CAPISTRANO.
Allen Jayne I sn an�p Inc.
Allen J,ayn a ins. Inc.
1833 V. Olympic Blvd tweLL & CrawFar
Los Angeles, CA 90006
CERTIFICATE OF INSURANCE
The City of San Juan Capistrano
32400 Paseo Adelanto
San Juan Capistrano, CA 92675
THIS IS TO CERTIFY as to the existence of insurance,as of the date of execution hereof,with Harbor Insurance Company,
as described below:
Name of Insured:
T. J. Crosby DEA: T. J. CFADSEY CO., 3TAL
Address of Insured:
P. O. Box 16489, Irvine, CA 92713
Location of Risk: Major Improvements of Streets and Sidewalks in San Juan
Kind of Insurance: Capistrano
Comprehensive General Liability
Policy No. 125940 period from 10-15-76 to 10-15-77
Limits: Bodily Injury each person $ 500,000.
each accident $ 500,000. aggregate $ 500,000.
Property Damage each accident $ 100,000. aggregate $ 100,000.
Kind of Insurance: Comprehensive Automobile Liability
Policy No. 125940 period from 10_15-76 to 30-15-77
Limits: Bodily Injury—each person $
_ 250,000.
each accident $ 500,000. aggregate $ 500,000.
Property Damage—each accident ' $ aggregate $
100,000. 100.000.
Kind of Insurance:
Policy No. period from to
Limits:
It is hereby understood and agreed that the certificate holder will be given ten (10) days written notice before any reduction of coverage or
cancellation of this insurance is effective.
This.Certificate of Insurance is issued as a matter oY information only and does not in any way amend, alter or vary the coverage afforded by the
policy or policies referred to herein and such policy or policies are subject to endorsement,alteration,transfer,assignment and cancellation according
to the terms,conditions and provisions of such policy or policies.
Dated et this day oftR11F(&Z11S'r" y'
Los Angllas, California 2nd Er 197
(MM OvZJQ
BY
-AILL-en Jayne Z Inc mt
ENDORSEMENT
IT IS UNDERSTOOD AND AGREED THAT THE CITY OF SAN JUAN CAPISTRANO IS (ARE)
NAMED HEREWITH AS AN ADDITIONAL INSURED UNDER THS POLICY BUT ONLY IN
CONNECTION WITH CONSTRUCTION BY T. J. CROSBY CO. OF MAJOR IMPROVEMENTS OF
STREETS AND SIDEWALKS IN SAN JUAN CAPISTRANO.
,
Allen Jayne In ra , Inc.
0 ENDORSEMENT • NO F> 22
INSURED DBA: T. J. CROSBY CO. , ET AL YY
PRODUCER ALLEN JAYNE INSURANCE INC. POLICY
THE EFFECTIVE DATE OF THIS ENDORSEMENT IS FEBRUARY 2, 1977 NO' 125940
TYPE OF COVERAGE COMPREHENSIVE GENERAL LIABILITY INCLUDING AUTOMOBILE BFJ/fCS
ADDITIONAL INSURED
B
(CONTRACTING OPERATIONS - FORM 11)
IT IS AGREED THAT SUCH INSURANCE AS IS PROVIDED BY THIS POLICY FOR BODILY INJURY LIABILITY -
EXCEPT AUTOMOBILE, AND PROPERTY DAMAGE LIABILITY - EXCEPT AUTOMOBILE APPLIES TO THE ADDI-
TIONAL INSURED NAMED HEREIN BUT ONLY WITH RESPECT TO OPERATIONS PERFORMED FOR SUCH ADDITIONAL
INSURED BY THE NAMED INSURED SUBJECT TO THE FOLLOWING PROVISIONS:
A CONDITIONS
1. LIMITS OF LIABILITY. THE LIMITS OF LIABILITY AFFORDED THE ADDITIONAL INSURED SHALL
NOT EXCEED THE LIMITS OF LIABILITY REQUIRED BY THE TERMS OR PROVISIONS OF THE PROJ-
ECT SPECIFICATIONS, CONTRACT OR AGREEMENT BETWEEN THE NAMED INSURED AND THE ADDI-
TIONAL INSURED BUT IN NO EVENT TO EXCEED THE LIMITS OF LIABILITY PROVIDED BY THIS
POLICY.
2. THE INSURANCE PROVIDED BY THIS POLICY APPLIES SEVERALLY AS TO EACH INSURED EXCEPT
THAT THE INCLUSION OF MORE THAN ONE INSURED SHALL NOT OPERATE TO INCREASE THE LIM-
IT OF THE COMPANY'S LIABILITY. INCLUSION HEREIN OF ANY PERSON OR ORGANIZATION AS
AN ADDITIONAL INSURED SHALL NOT AFFECT ANY RIGHT WHICH SUCH PERSON OR ORGANIZATION
WOULD HAVE AS A CLAIMANT IF NOT SO INCLUDED.
3. NOTICE OF CANCELLATION. THE COMPANY AGREES WITH THE ADDITIONAL INSURED TO PROVIDE
TEN (10) DAYS WRITTEN NOTICE BY CERTIFIED MAIL OF REDUCTION IN COVERAGE OR CAN-
CELLATION OF THIS INSURANCE.
B EXCLUSIONS. THE INSURANCE PROVIDED BY THIS ENDORSEMENT DOES NOT APPLY TO:
1. DAMAGES ARISING OUT OF ANY PROFESSIONAL SERVICES PERFORMED BY OR FOR THE ADDITIONAL
INSURED, INCLUDING:
(a) THE PREPARATION OR APPROVAL OF MAPS, PLANS, OPINIONS, REPORTS, SURVEYS, DESIGNS
OR SPECIFICATIONS AND
(b) SUPERVISORY, INSPECTION OR ENGINEERING SERVICES.
2. LIABILITY ASSUMED BY THE ADDITIONAL INSURED.
Nuorm
ADDITIONAL INSURED PROJECT OR CONTRACT DESCRIPTION
THE CITY OF SAN JUAN CAPISTRANO MAJOR IMPROVEMENTS OF STREETS AND
32400 PASEO ADELANTO, SAN JUAN CAPISTRANO, SIDEWALKS IN SAN JUAN CAPISTRANO
CALIFORNIA 92675 (TERM OF JOB: 120 CALENDAR DAYS)
NOTHING HEREIN CONTAINED SHALL BE HELD TO VARY. ALTER. WAIVE OR EXTEND ANY OF THE TERMS. CONDITIONS. OR LIMITATIONS OF THE
POLICY TO WHICH THIS ENDORSEMENT IS ATTACHED OTHER THAN AS ABOVE STATED.
fflRBOR INSURAtNCE COMPANY
447
DA
n°LOS ANGELES, CALIFORNIA THIs STEL °Ar of MARCH, 1977 °Y AUTH&IHE nVE
LAB 608
HU 8003-3 (ED. 3-'Z)f20M 6/76)