04-0929_AUSTIN-FOUST ASSOCIATES, INC._Insurance CertificateAMM CERTIFICAN OF LIABILITY INSUGME 1 DAM 1
Dealey, Renton & Associates
199 S Los Robles Ave Ste 540
Pasadena, CA 91101
626 844-3070
INSURED
Austin Foust Associates, Inc.
2020 North Tustin Avenue
Santa Ana, CA 92705
[K6114=10AHay
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
INSURER A: United States Fidelity & Guaranty
INSURER B: St. Paul Fire & Marine Ins. Co.
INSURER c XL Specialty Insurance Co.
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.
(NSR rypE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR DATE MM/DD/YY DATE M/DD/YY
A
GENERAL LIABILITY BKO1261229
08115/04
08/15/05
EACH OCCURRENCE $1.000.000
X ,, !COMMERCIALLIABILITY_OCCUR
DAM AGE (Any one lire) $1,000,000
PRE
MAOEER
LLLFIRE
_ _
(Any one person) $10,000
PERSONALS ADV INJURY_ $1,000,000 _ _
r
II
GENERAL AGGREGATE s2,000,000 _
IGEN'LAGGREGATELIMITAPPLIESPER'.
PRODUCTS_COMPIOP AGG $2000000_
Ilrr POLICY PRO- LOC
JECLA
AUTOMOBILE LIABILITY
BKO1261229
08/15/04
08/15/05 COMBINED SINGLE LIMIT
E. accident) $1,000,000
ANY AUTO
OWNED AUTOS
—I SCHEDULED AUTOS
BODILY INJURY
(Perpamm) $
X HIRED AUTOS
—11
BODILY INJURY
--ALL
X NON -OWNED AUTOS
(Pereccident) $
PROPERTY DAMAGE $
(Peraccident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
ANY AUTOEA
I OTHER THAN ACC $
AUTO ONLY: AGO $
A
EXCESS LIABILITY BKO1261229
08/15/04
08115/05 EACH OCCURRENCE $4,000,000
—
X -OCCUR CLAIMS MADE I
��
AGGREGATE $4,000,000
_
$
DEDUCTIBLE
_ $
RETENTION $
$
B WORKERS COMPENSATION AND
WVA7726345
09/01/04 09/01/05 X WCSTATU- OTHH-
T RV LIMIT
EMPLOYERS'LIABILITY
I E.L. EACH ACCIDENT $1,000,000____ _
E.L. DISEASE -EA EMPLOYEEI$1,000,000
E.L. DISEASE -POLICY LIMIT ' $1,000,000
C I OTHER Professional DPR9400354
03/25/04 03/25/05
$1,000,000 per claim
(Liability
$2,000,000 annl aggr.
DESCRIPTION OF OPERATONSILOCATIONS/VEHICLESrEXCLUSIONS 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 BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TOMAIL3O _DAYSWRITTEN
NOTICE TOTHE CERTIFICATE HOLDERNAM ED TOTH E LEFT, BUT FAILURE TO DOSOSHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURERJTS AGENTS OR
AUTHORIZED
1 of 1 #S112101/M111413 I- JMV 0 ACORD CORPORAgnOl11988
0 0
Policy Number: BKO1261229
Owners Lessees or Contractors (Form B)
ADDITIbNAL INSURED
Change(s) Effective: 09/29/04
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 .
CL/BF 22 40 03 95