04-0406_AUSTIN-FOUST ASSOCIATES, INC._Insurance CertificateClient#: 50 us nruua
ACr<'1iRD CERTIFICATE OF LIABILITY INSMANCE oailis/o °""'
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Dealey, Renton & Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
199 S Los Robles Ave Ste 540 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Pasadena, CA 91101
626 844-3070 INSURERS AFFORDING COVERAGE
irisunEo INSURER A: United States Fidelity & Guaranty
Austin Foust Associates, Inc. INSURER B: St. Paul Fire & Marine Ins. Co. _
2020 North Tustin Avenue INSURER C: XL Specialty Insurance Company
Santa Ana, CA 92705 INSURER D:
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.
INSR'I POLICY EFFECTIVE POLICY EXPIRATION LIMITS
E
LTR TYPE OF INSURANCE POLICY NUMBER TAD MM/DD/YY DATE WDMY
A
GENERAL LIABILITY BKO1261229
06/15/03
08/15/04
EACH OCCURRENCE $3,000,000
X COM M ERCIAL GENERAL LIABILITY
CLAIMS MADE rXJ OCCUR
FIRE DAMAGE (Any one fire) $300000 _
MED E%P (Any one person) $5,000
PERSONAL & ADV INJURY s3,00 000 _
GENERAL AGGREGATE_ s5,000,OOO_ _
GEN'L AGGREGATE LIM IT APPLIES PER:
PRODUCTS - COMP/OP AGG $5,000,000
PEO-
POLICY CT LOC
A AUTOMOBILE LIABILITY
BKO1261229
08/15/03
08/15/04
COMBINED SINGLE LIMIT $3,000,000
ANY AUTO
(Ea accident)
BODILY INJURY $
L ALL OWNED AUTOS
SCHEDULED AUTOS
(Per person)
�$
X HIRED AUTOS
BODILY INJURY
X NON -OWNED AUTOS
(Per accident)
_
PROPERTY DAMAGE
$
1
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
$
OTHER THAN EA ACC
$
ANV AUTO
_
$
AUTO ONLY: AGG
EXCESS LIABILITY�
EACH OCCURRENCE
$
AGGREGATE $
OCCUR JI CLAIMS MADE
I $
$
DEDUCTIBLE
RETENTION $
5
B
WORKERS COMPENSATION AND
WVA7726345
09/01/03
09/01/04
X WC STATU- OTH-
T RYLIMIT ER
E.L. EACH ACCIDENT
EMPLOYERS' LIABILITY
$1,000,000
E.L. DISEASE- EA EMPLOYEE
$1,000,000 _
E.L. DISEASE -POLICY LIMIT
i $1,000,000
C
OTHER Professional
DPR9400354
03/25/04
03/25/05 $1,000,000 per claim
Liability
$2,000,000 annl aggr.
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
Re: Plan Check Services
City of San Juan Capistrano is additional insured on the commercial
general liability and the hired and non -owned liability.
City of San Juan Capistrano
Attn: City Clerk's Office
32400 Paseo Adelanto
San Juan Capistrano, CA 92675
SHOULD ANYOFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHEE%PIiIATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3O—DAYS WRITTEN
NOTICETOTHE CERTIFICATE HOLDERNAMED TOTHELEFT, BUTFAILURE TODDSOSNALL/
IMPOSE NOOBLIGATION OR LIABILITYOF ANY KIND UPON THE INSURERJTS AGENTS O�1
AUTHORIZED
ACORD25-S(7/97)1 oft #M101324 E JMV oACORD
Policy Number: BKO1261229
Owners Lessees or Contractors (Form B)
ADDITI6NAL INSURED
Change(s) Effective: 04/06/04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT
CAREFULLY. This endorsement modifies insurance policy under the following:
LIABILITY COVERAGE PART:
Schedule
Name of Person or Organization:
City of San Juan Capistrano
Attn: City Clerk's Office
32400 Paseo Adelanto
San Juan Capistrano, CA 92675
SECTION II - WHO IS AN INSURED 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.
Re: Plan Check Services City of San Juan Capistrano is additional
insured on the commercial general liability and the hired and
non -owned liability .
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