1997-0528_PETAR ARTUKOVICH CONSTRUCTION_Insurance Certificate . a :::::.•::•••:',.•::::,•:,,,:::.••:•••',,::'::::,I ISSUE DATE (MM/DD/YY)
ACOItIP® CERTIFICA:II OF INSURANCE
05/28/97
PRODUCER THIS.,CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
CONFEHS"'O RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
SMITH-NEWMAN & ADAMSON AGENCY POLICIES BELOW.
285 IMPERIAL HWY.
SUITE 104 COMPANIES AFFORDING COVERAGE
FULLERTON CA 92635-
COMPANY A PACIFIC INSURANCE CO. LTD
LETTER
COMPANY B TRAVELERS INDEMNITY OF IL
INSURED LETTER
COMPANY `. COMMERCIAL UNDERWRITERS
PETAR ARTUKOVICH CONST. CO. LETTER
8243 SERANATA DRIVE
COMPANY D
WHITTIER CA 90603 LETTER
COMPANY E
LETTER
: : :VERA E :::: .......
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 LfS
LTR DATE (MM/DD/YY) DATE(MM/DD/YY)
A GENERAL LIABILITY Z10005258 09/24/96 09/24/97 GENERAL AGGREGATE $
2000000
X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGO. $ 1000000
CLAIMS MADE X OCCUR. PERSONAL&ADV.INJURY $ 1000000
X OWNER'S&CONTRACTORS PROT. EACH OCCURRENCE S 1000000
FIRE DAMAGE(My one Ike) $ NIL
MED.EXPENSE(My one person)$ NIL
B AUTOMOBILE LIABILITY 7EE-CAP-257T837-796 09/24/96 ' 09/24/97 COMBINED SINGLE
X ANY AUTO LIMIT $ 1000000
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) S
X HIRED AUTOS BODILY INJURY
X NON-OWNED AUTOS (Per accident) S
GARAGE LIABILITY •
PROPERTY DAMAGE S
A EXCESS LIABILITY UL001502 0 09/24/97 EACH OCCURRENCE S 1000000
X UMBRELLA FORM AGGREGATE $ 1000000
OTHER THAN UMBRELLA FORM
STATUTORY LIMITS
WORKER'S COMPENSATION
AND EACH ACCIDENT S
DISEASE-POLICY LIMIT S
EMPLOYERS'LIABILITY
DISEASE-EACH EMPLOYEE S
OTHER
DESCRIPTION OF OPERATIONS/L OCATIONSNEHICLES/SPECIAL ITEMS
PROJECT: MARBELLA GRAVITY SEWER
ADDITIONAL INSURED & COVERAGE IS PRIMARY PER THE ATTACHED ENDORSEMENT CG2010
...................... . . ............
;CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
iiie
`` EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL 1M-Mw
CITY OF SAN JUAN CAPISTRANO MAIL _3°_ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
32400 PASEO ADELANTO LEFT, _ __ - .. -
SAN JUAN CAPISTRANO CA 92675 hilillipliiiiiiikiliellelliMINEW
AUTHORIZED REPRESENTATIVE
SUZANNE ADAMS X! Q, 1 1)(1.
1. 11, 1 1 t' -A 1/1,, n
ACORD 25-S (7190) OACORD CORPORAInO$ 1 ?:.
.
POLICY NUMBER: COMMERCIAL GENERAL LIABILITY
•Z10005258 .
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS (FORM B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
Name of Person or Organization:
The City of San Juan Capistrano, its elected or appointed officers,
officials, employees and volunteers
(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, but only with respect to liability arising out of "your work" for that insured by or for you.
THE INSURANCE AFFORDED TO THE ADDITIONAL INSURED UNDER THIS
ENDORSEMENT SHALL BE PRIMARY AS TO ANY OTHER INSURANCE
COVERING OR AVAILABLE TO THE ADDITIONAL INSURED AND SUCH
OTHER INSURANCE SHALL NOT BE REQUIRED TO CONTRIBUTE TO ANY
LIABILITY OR LOSS UNTIL AND UNLESS THE APPROPRIATE LIMIT OF
LIABILITY HEREUNDER IS EXHAUSTED.
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.
CG 20 10 11 85 Copyright, Insurance Services Office, Inc., 1984 ❑