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11-0201_ORANGE COUNTY CONSERVATION CORPS_Insurance Certificate-~ OP ID: PC , RLX CERTIFICATE OF LIABILITY INSURANCE D� �D11nYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFjCAT­EyH2OLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERA _-A FO,F2<7Eq BY >THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE lS�lf1N INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If I( ItlIS ! D inject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this c lc t o is not confer rights to thto certificate holder in lieu of such ondorsement(s). j PRODucER 626-405-$031 Chapman 626-405-0585 License #0522024 P. O. Box 5455 Pasadena, CA 911'17-0455 1 Iaan"E: _ 46° Ext): (A/ ) - ,-I — - EMAIL ADDRESS: INSRii POLICY EFF POLICY EXP i LTR TYPE OF INSURANCE I' WVD POLICY NUMBER M_M1�DIYYYY� AAPhlD�lYYYY LIMITS -- PRODucER .ANG -9 cusraM(RIDn: __._— _.. INSURER( JAFFORD[NG COVERAGE NAIC, ###� [ INSURED Orange County Conservation Cor INSURER A; Great American Insurance Co 16699 Tai Tony Huynh INSURER B: Carolina Casualt Ins Co 10510 1853 N. Raymond Ave. Anaheim CA 92801 _ W _... __.. ..._ .._-___. _._..Y ...�.._..... �_._.._._......_.__._.___...__..-I INSURER_C : Nonprofits' insurance Alliance 10023 i ___..._...Y r- [ INSURER D ; AGGREGAT GI ELfM€7A>PLOC�._..�.� INSURER E PRODUCTS - GO'JcPfOP AGG $ 3,000,000 _. _.. ......... ..... XEN'L CY.�..m POLI1, I� INSURER F : - Ellttp Ben@f $ 1,000,000 AUTOMOBILE LIABTUTY j ', COVERAGES CERTIFICATE NUMBER; REVISION NUMBER: I, --- j J THIS IS TOCERTIFY 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. INSRii POLICY EFF POLICY EXP i LTR TYPE OF INSURANCE I' WVD POLICY NUMBER M_M1�DIYYYY� AAPhlD�lYYYY LIMITS -- GENERAL LIABILITY EACH OCCURRENCE i $ - 1,000,000 jjjI A X GENERALX LIAEILITY ie ''� PAC5154680 07120/10 07/20111 MA IILNII-LI AREMISES(Eaoccurrence) $ 100,000 !COMMERCIAL - CLAIMS-hhA^E OCCUR 3 MED EXP (Any one arson � 5,000 i....,.__,,,,.........r........._._.,,,,....._.,.,.,,,-_,,,,,..................r.,,,_„_ PERSC7NAL&AC7V1N.iURY 5 1,000,000 I GENEt2ALAGGR GATE S 3,000,000 AGGREGAT GI ELfM€7A>PLOC�._..�.� PRODUCTS - GO'JcPfOP AGG $ 3,000,000 _. _.. ......... ..... XEN'L CY.�..m POLI1, I� Ellttp Ben@f $ 1,000,000 AUTOMOBILE LIABTUTY j ', COMBINED SINGLE LIM7 fi I, --- j J {Ea aocidenf) : ANY AUTO !, BODILY INJURY (Per person)ALL - $ I OS BODILY INJURY (Per accident) $ SCHODULED AU i I ....._.._........_.............. _,_,� PROPERTY DAMAGE uHIREDAUTOS 1 (Per accident) NON -OWNED AUTOS ? ' S 3 $ UMBRELLA LIAR OCCUR____„_ —. EACH OCCURRENCE $ EXCESS LIAR CLAIMS -MADE AG_GRF_GATE _ DEDUCTIBLE - RETENTION $ l $ WORKERS COMPENSATIONH- j XAND :ORYLiMITS ER EMPLOYERS' LIABILITY C ANY PRC RiETORIPARTNERlEXECUTIVEYJN NPEIWCG0012011 01/07/11 1 01101112 ii E LEACH ACCIDENT S1,000,000 __._. ... 0FFICERIMEM€BER EXCLUDED? NIA E.L. DISEASE- EA EMPLOY_EF S 1,000,000 i (Mandatory in NH) I I Ves describe under SSCRIPTIONOFOPF_RAT?ONSielow j E E. L. DISEASE -POLICY LIMIT S 1,000,000 -- A Property coverage PAC5754680 07/20/70 07120111W- - DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedute, if mare space is required) Re: Premise. City of San Juan Capistrano is named additional insured with respect to the operations of the named insured. Waiver of Subrogation for Workers Compensation policy applies in favor of certificate holder - endorsement to follow. C:tK I It-IUA I It MULUtK CITYSAU City of San Juan Capistrano 32400 Paseo Adelanto San Juan Capistrano, CA 92675 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE O 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD —'�� A rninistr five offices 58 'Na[nuStreet Cincinnati, Ohio 45202 RE ATAMERICAN, 19T: lriOPR CG 82 24 (Ed. 12 011 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. SOCIAL SERVICE AGENCY GENERAL LIABILITY BROADENING ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART 1. The following provision is added to SECTION II - WHO IS AN INSURED 5. AUTOMATIC ADDITIONAL 1NSUREDIS) a, Additional Insured - Manager or Lessor of Premises (1) This policy is amended to include as an insured any person or or- ganization (hereinafter called Ad- ditional Insured) from whom you lease or rent property and which requires you to add such person or organization as an Additional Insured on this policy under: (a) a written contract; or (b) an oral agreement or con- tract where a Certificate of Insurance showing that per- son or organization as an Additional Insured has been issued; but the written or oral contract or agreement must be an "insured contract," and, (I) currently in effect or be- come effective during the term of this policy: and (ii) executed prior to the 'bodily injury,` "property damage," "personal and advertising in- jury „ (2) With respect to the insurance af- forded the Additional Insured identified in Paragraph A.(1) of this endorsement, the following additional provisions apply: (a) This insurance applies only to liability arising out of the ownership, maintenance or use of that portion of the premises leased to you. (b) The Limits of Insurance ap- plicab(e. to the Additional In- sured are the lesser of those specified in the written con- tract or agreement or in the Declarations for this policy and subject to all the terms, conditions, and exclusions for this policy. The Limits of Insurance applicable to the Additional Insured are inclu- sive of and not in addition to the Limits of Insurance shown in the Declarations. (a) In no event shall the cov- erages or Limits of Insurance in this Coverage Form be in- creased by such contract. (d) Coverage provided herein is excess over any other valid and collectible insurance available to the Additional In- sured whether the other in- surance is primary, excess, Includes copyrighted material of Insurance Service Office with its permission. Copyright, Insurance Services Office, Inc.. 2001 CG 82 24 (Ed. 12101) XS (Page 1 of 4) contingent or on any other basis unless a written con- tractual arrangement specifi- cally requires this insurance to be primary. (3) This insurance does not apply to: (a) Any `occurrence" or offense which takes place after you cease to be a tenant in that premises. (b) Structural alterations, new construction or demolition operations performed by or on behalf of the "Additional Insured." b. Additional Insured - Funding Sources (1) This policy is amended to include as an Insured any Funding Source which requires you in a written contract to name the Funding Source (hereinafter called Addi- tional Insured) as an Insured but only with respect to liability aris- ing out of your premises, 'your work" for such Additional Insured; or acts or omissions of such Ad- ditional Insured in connection with the general supervision of "your work" and only to the extent set forth as follows: (a) The Limits of Insurance ap- plicable to the Additional In- sured are the lesser of those specified in the written con- tract or agreement or in the Declarations for this policy and subject to all the terms, conditions, and exclusions for this policy. The Limits of Insurance applicable to the Additional Insured are inclu- sive of and not in addition to the Limits of insurance shown in the Declarations. (b) The coverage provided to the Additional Insured(s) is not greater than that cus- tomarily provided by the policy forms specified in and required by the contract. (c) In no event shall the cov- erages of Limits of Insurance in this Coverage Form be in- creased by such contract. c. Additional Insured - Contractual Obligations (1) This policy is amended to include as an Insured any person or or- ganization (hereinafter called Ad- ditional Insured) that you are re- quired by a written "insured con- tract" to include as an Insured, subject to all of the following provisions: (a) Coverage is limited to liability arising out of: (i) your ongoing oper- ations performed for such Additional Insured; or (ii) that insured's financial control of you; or (iii) the maintenance, opera- tion or use by you of equipment leased to you by such Additional Insured; or (iv) a state or political sub- division permit issued to you. (b) Coverage does not apply to any "occurrence" or offense: (i) which took place be- fore the execution of, or subsequent to the completion or expira- tion of, the written "in- sured contract", or (ii) which takes place after you cease to be a ten- ant in that premises. Includes copyrighted material of Insurance Service Office with its permission. Copyright, Insurance Services Office, Inc., 2001 CG 82 24 (Ed. 12/01) XS (Page 2 of 4) (c) With respect to architects, engineers, or surveyors, coverage does not apply to "Bodily Injury," "Property Damage," "Personal and Ad- vertising Injury" arising out of the rendering or the fail- ure to render any profes- sional services by or for you including: (i) the preparing, approv- ing, or failing to pre- pare or approve maps, drawings, opinions, re- ports, surveys, change orders, designs or specifications, and {iii) supervisory, inspection, or engineering services. If an Additional Insured endorsement is at- tached to this policy and specifically names a person or organization as an Insured, then the coverage in Section II - WHO IS AN INSURED 5. Automatic Additional Insured(s) does not apply to that person or organization. 2. BLANKET WAIVER OF SUBROGATION SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, Item 8. is replaced with: 8. Transfer of Rights of Recovery Against Others to us and Blanket Waiver of Subrogation a. If an Insured has rights to recover all or part of any payment we have made under this Coverage Part, those rights are transferred to us. The Insured must do nothing after loss to impair them At our request, the Insured will bring "suit" or transfer those rights to us and help us enforce them. b. If required by a written "insured con- tract", we waive any right of recovery we may have against any person or organization because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract for that person or organization and included in the "products -completed operations hazard." 2. NDN -OWNED DIS CHARTERED WATER- CRAFT Section I - Coverages, Coverage A. Item 2.9.0 is replaced with: (2) A watercraft you do not own that is: (a) less than 51 feet long; and (b) not being used to carry persons or property for a charge. 4. BROADENED PERSONAL AND ADVERTISING INJURY Unless "Personal and Advertising Injury" is ex- cluded from this policy: SECTION V - DEFINITIONS Item 14. is re- placed by: 14. "Personal and Advertising Injury" means injury, including consequential 'bodily in- jury," arising out of one or more of the following offenses: a. false arrest, detention or imprison- ment; b. malicious prosecution; c, the wrongful eviction from, wrongful entry into, or invasion of the right of private occupancy of a room, dwelling or premises that a person occupies by or on behalf of its owner, landlord or lessor; d. oral, written, televised, videotaped, or electronic publication of material, in any manner, that slanders or libels a person or organization or disparages a person's or organization's goods, pro- ducts or services, e. oral, written, televised, videotaped, or electronic publication of material, in any manner, that violates a person's right of privacy; or Includes copyrighted material of Insurance Service Office with its permission. Copyright, Insurance Services Office, Inc., 2001 CG 82 24 (Ed. 12/01) XS (Page 3 of 4) f. mental injury, mental anguish, humili- ation, or shock, if directly resulting from Items 14.a. through 14.e. g. the use of another's advertising idea in your "advertisement", or h. infringing upon another's copyright, trade dress or slogan in your "adver- tisement." 5. MENTAL INJURY, MENTAL ANGUISH, HUMILIATION, OR SHOCK INCLUDED IN BODILY INJURY DEFINITION Section V - Definitions, Item 3. is replaced with: 3. "Bodily injury" means physical injury, sick- ness, or disease, including death of a per- son. "Bodily injury" also means mental in- jury, mental anguish, humiliation, or shock if directly resulting from physical injury, sickness, or disease to that person. 6. MEDICAL PAYMENTS A. The Medical Expense Limit in Paragraph 7. of SECTION III - LIMITS OF INSURANCE is replaced by the following Medical Ex- pense Limit. The (Medical Expense Limit provided by this policy shall be the greater of: a. $10,000, or b. The amount shown in the Declarations for Medica[ Expense Limit. B. This provision 7_ is subject to all the terms of SECTION Ill - LIMITS OF INSURANCE. C. This provision 7. does not apply if COVERAGE C. MEDICAL PAYMENTS is excluded either by the provisions of the Coverage Part or by endorsement. 7. DAMAGE TO PREMISES RENTED TO YOU LIMIT A. SECTION III - LIMITS OF INSURANCE, Item 6. is replaced with: Subject to x. above, the Damage to Prem- ises Rented to You Limit is the most we will pay under Coverage A for damages because of "property damage" to your building, or to personal property of others in your care, custody and control while at premises rented to you or temporarily occupied by you with permission of the owner, arising out of any one fire. The Damage to Premises Rented To You Limit is replaced by the following Damage to Premises rented To You Limit. The Damage to Premises Rented To You Limit is the greater of: (1) $500,004: or (2) the amount shown in the Declarations for Damage to Premises Dented to You Limit, B. This provision is subject to all the terms of SECTION III - LIMITS OF INSURANCE. C. This provision 5. does not apply if Damage to Premises Fent to You Liability of COV- ERAGE A (SECTION 1) is excluded either by the provisions of the Coverage Part or by endorsement. 9. SUPPLEMENTARY PAYMENTS A. In the SUPPLEMENTARY PAYMENTS - COVERAGES A and B provision, Item 1.b., and 1.d are replaced with: 1.b. tip to $500 for cost of bail bonds required because of accidents or traf- fic law violations arising out of the use of any vehicle to which the Bodily In- jury Liability Coverage applies. We do not have to furnish these bonds. 1.d. All reasonable expenses incurred by the Insured at our request to assist us in the investigation or defense of the claire or "suit," including actual.loss of earnings up to $500 a day because of time off work_ This endorsement does not change any other provision of the policy. Includes copyrighted .material of Insurance Service Office with its permission. Copyright, Insurance Services Office, Inc., 2001 CG 82 24 (Ed. 12/01) XS (Page 4 of 4) OP 10: PC ' `C7"R ` ` CERTIFICATE OF LIABILITY INSURANCE12/15 CAATD3YYYY) '!2115170 P #1RrG I TE1;IdAkE HOLDER. THIS THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTSMP CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE CdVE" 1= AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. 1 r, p IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(les) must he endorse !0131406A 10 IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not Confer rights to the certificate holder in Ilou of such endorsement(s). :. PRODUCER 626-405-8031 Chapman 626-405-0585 License #0522024 P. 0. Box 5455 Pasadena, CA 99117-0455 CONTACT - CONT .. PHONE � . 'i „ - ; , . , .::. FAX M`L �xc : ADURESS. PRODUCER gF�ANCs cuaTflMER D INSURER(S) AFFORDING COVERAGE NAIC ff _......._..,._...._,_._.-._.....___ INSURED Orange County Conservation Cor � Tai Tony Huynh 1853 N. Raymond Ave. Anaheim, CA 92801 INSURERA. NlonProfits United INSURER 6: GENERAL LIABILITY INSURERD: INSURER E: INSURER E' COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 DESCRIBER HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSION AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ........ ...�..W INTR TYPE OF INSURANCE ADDL N us + POLICYNUMBER PCILICY EFF M01 POLJCY EXP MM❑ Y LIMITS San Juan Capistrano, CA 92675 GENERAL LIABILITY EACH OCCURRENCE 5 OREMISES6HEF)T 1 COMMERCIAL GENERAL LIABILITY rfonc— Fi"2Eh115E5(f"tieLCerraRC9) CLAIMS -MADE 17 OCCUR 1vfED EXP (Any one person) $ PERSONAL & AEV INJURY $ GENERAL AGGREGATE $ GFN`LAGGREGATELIMIT APPUESPER, PRODUGTS-COMPIOPAGG $ POLICY _ PRO-JEQ[L. $ A .AUTOM081i.E X LIAeIWTY ANY AU"J'O 1560 0710V10 07101/11 COMB)NF'E SINGLE t. MIT (Ea &rxidanlj $ 1,000,€100 BODILY INJURY (Per Person) $ AIJ_ OW NEE AUTOS 801311„Y INJURY (Par 9cnident) 5 . SCHEWLr=O AUTOS HIRED AUTOS PROPERTYOAMAGE €Pe3• scc€den!) $ NON•owNEDAUTos UMBRELLA LIAROCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAIS CLAIMS -MADE $ WDUCTtKIE ! RETENTION WORKERS COMPENSAMN WC 'TATO• OTH- AND EMPLOYERS' LIABILITY Y N ----------- ANYPROPRIErORfPARTNERIEXECUTIVE� 0PFICERiMEMBEREXCLUD7 N/A - E,L,EACIIACClOENT -...... _......W...._.___.__.,_.. $ ._._,_ (Mandatary in NH) E.I.„ EISEASC» EA EMPLOYE r $ ._._ �� I{Yes. dbsr.•riinr� under W9GRIPTM OP OPERATIONS helaw F.L. DISEASE- POLICY LIMIT $ 13rsc lPTION OP OPERATIONS! LOCAT€ONS 1 VIEHICLES (Attach ACORD IN, AddWonal Remarks Sched0a, If mora epa� Is required) Evidence of coverage, 10 days notice of cancellation for non-payment of premium. rP:RTIFI('.ATF Hf)i nFR rAKICF.1_.I ATION C iTYSAU SHOULD ANY OF THE ABOVE DESORISE13 POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of San Juan Capistrano 324.00 Paseo Adelanto AUTHORtzEPREFRESENTATtVE San Juan Capistrano, CA 92675 C 1388-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD �E-Verff Company ID Number: 390867 C 2611 1 F8 t 0 A To be accepted as a participant in E -Verify, you should only sign the Employer's Section of the signature page. If you have any questions, contact E -Verify & ...... ......... ....... . . ..... ............................................................................................................ ................................................................................................. ........ ............................................................................................... . . ..... ... ... .. .... Employer Orange County Conservation Corps Tonv Huvnh ----- -------------- -------------- ­­ -------------­ ­ . ...... .... ..... ....... ... .. ... Name (Ptease Tvpe or Print) 1 rtment of Homeland Security — Verification Division ISCIS Verification Division ......... . . ... ........ .................. .......... ............ . . . . .... T. 1.1.111, . . .. ......... ..... ame ease Type or Print) Title lectronicaliv Signed 02/08/2011 ate Information Required for the E -Verify Program nformation relatinci to vour Cornmw Company Name: range County Conservation Company Facility Address -.111863 N. Raymond Ave. Company . .. ..... .. ... .. ... ...... ....... .... Anaheim, CA 92801 Company Alternate Address: County or Parish: ORANGE Employer Identification Page 12 of 13 1 E -Verify NEO U for Employer I Revision Date 09/01109 www.dhs.gov/E-Verify Company ID Number: 390867 ........... North American Industry Information relating to the Program Administrator(s) for your Company on policy questions or operational problems: Nance: ` G11V Iluvnh `€'elepho}ne Number: (714) 956 - 6222 Fax Numlxr: (714) 956 - 1944 € -mail Address: thuynh!