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1997-0701_BOYS & GIRLS CLUB OF CAPISTRANO VALLEY_Insurance o:o» �t k ?3k"< 10/28/99 Producer THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION MANION/BELL INSURANCE ASSOCIATES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P. O. BOX 36186 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR LOS ANGELES,CA.90036 _ ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW (213)387-8294*FAX(213)389-5833 COMPANIES AFFORDING COVERAGES LIC.#0655274 Comwoy mored A MARKEL INSURANCE COMPANY (J biJ Company ALL BOYS AND GERLS CLUB OF CAPISTRANO VALLEY B 31371 EL CAMINO REAL Comwny SAN JUAN CAPISTRANO,CA.92675 C COmR.OY D px� R M THIS POLICIES TO CERTIFY THAT THE POLICIES OF INSURANCE LI 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 PERFAIN.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 POLICY LTRTYPE OF INSURANCE NUMBER INCEPTION EXMRAnON LIMITS A coMM.OE7'"A"MY 850-2CY009-485 I I/I/99 11/1/00 GENERAL AGGREGATE 93.000,000.00 ocwRRENce TOR. PRODUCTS•COMP/OP AGG $1,000,000.00 OTHER PERSONAL&ADV INJURY 91,000.000.00 EACH OCCURRENCE $1,000.000.00 FIRE DAMAGE(Any one fire) $50.000.00 (EXCLUDING MEMBERS AND STAFF) MED EXPIAny one person) $5,000.00 AUTOMOBILE LIABILITY ANY AMO COMBINED SINGLE LIMIT ALL OWNEDAInOS BODILY INJURY SCIIEOUIEO ABIOS (Per person) HLMDAMOS BODILY INJURY NON-OWNED AUTOS (Per aodcl.ntl ACV Comprehensive&Collision less 5 250.Deductible SCHEDULED VEHICLE SHOWN BELOW = PROPERTY DAMAGE C EXCESS LIABILITY EACH OCCURRENCE C n UMSRELLA FORM AGGREGATE ' —H'TJ OTHERTHAN UMBRELLA FORM ACCIDENT COVERAGE MED LIMIT N T 3C r ILIMMANY SICKNESS SIFT Se.3"= Cn "I EXCESS DEDUCTIBLE Z 3 DEDVCT80 OTHER L17 OESMI'ON OF OPERAnOHiM1OG11NINeryENCLESISFEGAL ITEMS Certificate Holder is included as additional insured but only as respects the operations of the Named Insured performed. —Re: After School Recreation Programs/Real Property Lease Agreement v : ...... . ._.._..... ... h.�,L•}1ic....a:.$n.. �:z:;x naa�Ya. e. ,> �'.'`, .�c SHOULD ANY OFTHS ABOVE DESCRIBED POLICIES BE CANCELED BEFORE THE City of San Juan Capistrano EXPIRATION DATE THEREOF.WE ISSLUNG COMPANY WILL MAIL 30 DAYS it's officers, agents and employees WRITTEN NOTCE TO THE CERTIFICATE HOLDER NAMED TO WE LEFT(except 32400 Paso A Delanto in one ofnon-payment of premium wherein a 10 day notice will San Juan Capistrano, CA 92675 be given). AUTHOR12FO IHPRESE NTA D VE � t I ' POLICY NUMBER: 8602CY008486 • COMMERCIAL GENERAL ABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULL ADDITIONAL INSURED -=� DESIGNATED PERSON R ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: City of San Juan Capistrano its officers, agents and employees (I# no entry appears above, information required to complete this endorsement wi Declarations as applicable to this endorsement.) II be shown i the WHO IS AN INSURED (Section II) is emended to include as an Insured the person or or Schedule as an insured but only with respect to liability arising out of your operations ganshown n the rented to you. p s or preomismis n es owned by or CO 20 26 11 85 Copyright, Insurance Services Office, Inc., 1984 13 STATE P.O. BOX 807, SAN FRANCISCO,CA 94101-0807 n ..COMPENSATION r�"f"� INSURANCE 1 ^� FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE I✓ru��I(. ..� POLICY NUMBER: 1381364 - 00 ISSUE DATE: 01-01-00 CERTIFICATE EXPIRES: 01-01-01 CITY OF SAN JUAN CAPISTRANO JOB: 1. TEEN RECREATION BUILDING & SAFETY DEPARTMENT 2. AFTER-SCHOOL RECREAT. 32400 PASEO ADELANTO EMPLOYEES=2 SAN JUAN CAPISTRANO, CA 92675 This is to certify that we have issued a valid Workers' Compensation insurance policy in a from approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the fund except upon 10 days' advance written notice to the employer. We will also give you 10 days' advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies listed herein. notwithstanding any requirement, term, or condition of any contract or other document with respect to which this certificate of insurance 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. KPRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000.00 PER OCCURRENCE. c yiv+;m N < �sMM cm . azy z 0 8 EMPLOYER LEGAL NAME BOYS AND GIRLS CLUB OF CAPISTRANO BOYS AND GIRLS CLUB OF CAPISTRANO VALLEY VALLEY (A NON-PROFIT PUBLIC BENEFIT CORP) 31371 EL CAMINO REAL, S J CAPISTRANO CA 92675 PRINTED: 12-19-99 P0408 Q• A• dwaft 32400 PASEO ADELANTO MEMBERS OF THE CITY COUNCIL SAN JUAN CAPISTRANO, CA 92675 _ COLLEGE CAMPBELL muncrute JOHN G EINER ART (949) 493-1 171 - � wYArr HART (949) 493-1053 (FAX) nnnneu 1961 GIL JONES 1776 DAVID M.SWERDUN CIN MANAGER GEORGE SCARBOROUGH December 27, 1999 Mr. James L. Williams, Executive Director Boys and Girls Club of Capistrano Valley 31371 EI Camino Real San Juan Capistrano, California 92675 Re: Renewal of Workers' Compensation Certificate of Insurance (After School Recreation Programs/Real Property Lease Agreement) Dear Mr. Williams: The Workers' Compensation Certificate of Insurance, regarding the above-referenced agreements, is due to expire on January 1, 2000. In accordance with your agreements, the insurance certificate needs to be renewed for an additional period of one year. Please forward an updated certificate to the City of San Juan Capistrano, attention City Clerk's office, by January 10, 2000. If you have any questions, please contact me at (949) 443-6310. Thank you for your cooperation. Very truly yours, Xaw/)�J) ,%1V/ zd6le Dawn M. Schanderl Deputy City Clerk cc: Cheryl Johnson, City Clerk Karen Crocker, Community Services Manager DRUG USE IS B San ,luan Capisti-ono: Preserving the Yost to Enhance the Future :� • �!Ep�c ) M o�xc vi„ 10/28/99 Producer THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION MANION/BELL INSURANCE ASSOCIATES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O. BOX 36186 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR LOS ANGELES.CA. 90036 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW (213)387-8294*FAX(213)389-5833 COMPANIES AFFORDING COVERAGES LIC.N 0655274 Company Insured A MARKEL INSURANCE COMPANY Company BOYS AND GIRLS CLUB OF CAPIS7RANO VALLEY B 31371 EL CAMINO REAL Company SAN JUAN CAPISTRANO,CA.92675 C Company D Q.. .1' t"R":.Y:tiv:L,r. ahR :'ziSk�E: S`� @rle u °<"E:�i i:'i:'.:`e,'�r"z`o:E :a,�ble x' .:3n>a,<:<, . ...::¢:s ke?i::::'c�:&:ttt.�.iz.:wt t: a :aux : 'kept:')e.l;k::<a:4.;:e:::<r:<::<t:is;� F 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 CONTRACTOR 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 POLICY LTR TYPE OF INSURANCE NUMBER INCEPTION E%PMAnON LIMITS A v cOMM.MNERAL Lweanv 850-2CY009-485 11/1/99 I1/1/00 GENERAL AGGREGATE $3,000,000.00 - - oecvRREn.FARM - - ---- - PRODUCTS•COMP/OP AGO $1,000,000.00 OMER PERSONAL&ADV INJURY $1,000,000.00 EACH OCCURRENCE $1,000,000.00 FIRE DAMAGE(Any one fire) $50,000.00 (EXCLUDING MEMBERS AND STAFF) MED EXPIAny one person) $5,000.00 AUTOMOBILE LIABILITY ANY Aurn COMBINED SINGLE LIMIT ALL OWNED AMOS BODILY INJURY SCHEDULED AUTOS )Per person) HIRED AMOS BODILY INJURY NONOWNED AMOS IPer accident) ACV Comprehensive&Collision less 5 250.Deductible SCHEDULED VEHICLE SHOWN BELOW p s PROPERTY DAMAGE c EXCESS LIABILITY EACH OCCURRENCE 2=m n UMRRELLA FORM AGGREGATE j'�,-� OTHER TITAN UMBRLLIA FORM —LO—LO—1 CO ACCIDENT COVERAGE MED LIMB PRIMARY SICKNESS n=-1 EXCESS DEDUCTIBLE CD OEDUCInLf OTHER DESCRIPTION OF ORERAnCMILOCATONSMENICLESISPECML ITEMS Certificate Holder is included as additional insured but only as respects the operations of the Named Insured performed. —Re: After School Recreation Programs/Real Property Lease Agreement SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELED BEFORE THE City of San Juan Capistrano EXPIRATION DATETHEREORTHE ISSUINGCOMPANY WILL MAIL30 DAYS It's officers, agents and employees WRITTEN NCTICETOTHE CERTIFICATE HOLDER NAMED TVTHE LEFT(ovCepl 32400 Paso A Delanto in case of non-payment of premium wherein a 10 day notice will San Juan Capistrano, CA 92675 be iven). AUTHORIZED RFPRESENTATIVF J 32400 PASEO ADELANTO MEMBERSOFTHE CITYCOUNCIL SAN JUAN CAPISTRANO,CA 92675 COLLENE CAMPBELL JOHN GREINER (949)493-1171 muvumo MATT HART (949)493-1053 (FAX) uunmu 1961 GIL JONES 1776 DAVID M.SWEROLIN CITYMANAGER • GEORGE SCARBOROUGH October 13, 1999 Mr. James L. Williams, Executive Director Boys and Girls Club of Capistrano Valley 31371 EI Camino Real San Juan Capistrano, CA 92675 Re: Renewal of General Liability Certificate of Insurance and Endorsement Form (After School Recreation Programs/Real Property Lease Agreement) Dear Mr. Williams: The General Liability Certificate of Insurance, regarding the above-referenced agreements, is due to expire on November 1, 1999. In accordance with your agreements, the insurance certificate needs to be renewed for an additional period of one year. The agreement requires a general liability endorsement form naming the City of San Juan Capistrano as an additional insured. Please forward the updated certificate and the endorsement form to the City, attention City Clerk's office, by the above due date. If you have any questions, please contact me at (949) 443-6310. Thank you for your cooperation. Very truly yours, muo_� Dawn M. Schanderl Deputy City Clerk Enclosure - Sample Endorsement cc: Cheryl Johnson, City Clerk Karen Crocker, Community Services Manager DRUG USE IS AD San Juan Capistrano: Preserving the Past to Enhance the Future / SG STATE P.O. BOX 807, SAN FRANCISCO,CA 94101-0807 �O�D • 3Q I N S U R A N COMPENSAT1C E FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE POLICY NUMBER: 1381364 - 99 ISSUE DATE: 01-01-99 CERTIFICATE EXPIRES: 01-01-00 CITY OF SAN JUAN CAPISTRANO JOB: ALL OPERATIONS BUILDING & SAFETY DEPARTMENT 32400 PASEO ADELANTO SAN JUAN CAPISTRANO, CA 92675 This is to certify that we have issued a valid Workers' Compensation insurance policy in a from approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the fund except upon 10 days' advance written notice to the employer. We will also give you 10 days' advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies listed herein. notwithstanding any requirement, term, or condition of any contract or other document with respect to which this certificate of insurance 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. 2�L�PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000.00 PER OCCURRENCE. O rn r-n W ' _ o F- n EMPLOYER LEGAL NAME BOYS AND GIRLS CLUB OF CAPISTRANO BOYS AND GIRLS CLUB OF CAPISTRANO VALLEY VALLEY (A NON-PROFIT PUBLIC BENEFIT CORP) 31371 EL CAMINO REAL, S J CAPISTRANO, CA 92675 PRINTED: 12-18-98 P0408 DOCUMENTTHIS _ (ocn. ac POLICY NUMBER: 8502CYO 9 - 4 `'COMMERCIAL GENERAL LIABILITY (3 irI'S 0—U-LC THIS ENDORSEMENT CHANGES THE POLI Y. PLEASE AD IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: o n COMMERCIAL GENERAL LIABILITY COVERAGE PART. o _ m SCHEDULE w rn w < Name of Person or Organization: rn City of San Juan Capistrano its officers, agents and employees CZ:' (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 IU is amended to include as an insured the person or organization shown in the Schedule as an insured but only with respect to liability arising out of your operations or premises owned by or rented to you. CG 20 26 11 85 Copyright, Insurance Services Office, Inc., 1984 POLICY NUMBER: 8502CY009485 - 4 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: Capistrano Unified School District Board of Trustees (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 as an insured but only with respect to liability arising out of your operations or premises owned by or rented to you. CG 20 26 11 85 Copyright, Insurance 5_ervices Office, Inc., 1984 El DEC CIS '98 03:48F'PI EI HIiU I; CLI_IE CHFYJ F. 1 1 At RECEIVED 32400 PASEO AOELANTO 1 I, � © Il �� I '.fE4.^EnS Qe TLEC PlCCAWPHL: SAN JUAN CAPISTRANO,CA 92675 ILLI 4 .' CxN GriENE INCA EI. ,,. q WYAT Cf;E Y (9491493-I 171 1//`� u� vurn; II "� w�va7r naa7 (949)493-1033 (FAX) ,I...nu. 1961 GE:o,+sG 1776 DAVID M ;vrP.o I'- CRY MANAGER GEORGE SCARBOROUGH 0C December 7, 1998 19 �94% Mr. Jim Williams, Executive Director Boys & Girls Club of Capistrano Valley 31371 EI Camino Real San Juan Capistrano, California 92675 Re: After School Recreation and Teen Programs Dear Mr. Williams: At their meeting of December 1, 1998, the City Council of the City of San Juan Capistrano took action to approve an extension of the After School Recreation and Teen Program agreements. The agreements will continue in effect for a six-month period ending June 30, 1999. The insurance required by the contracts has been received with the exception of the liability endorsement form naming both the City and the Capistrano Unified School District as additional insured. Please forward the endorsement form to the City Clerk's office as soon as possible. We would also like to bring to your attention that the required Worker's Compensation certificate Qlf expire on January 1, 1999 and a renewed certificate will be needed. Thank you for your assistance. Please feel free to contact Karen Crocker at 443-6389 if you have any questions. Very truly yours, OUTING&REQUEST 611zzlt Please... To: Approve ad Cheryl Johnson +4 � e� oll City Clerk ( t cc: Karen Crocker Forw n From: ❑ Return ❑ Keep or Toss ❑ Review with Me Date: } San Juan Capistrano: PreseI_'iIla Po.-t 79 CCWIS l AC�I CERTIFICATE OF INSURANCE - ISSUE DATE(MM/DD/yyI 11-17-1998 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS Markel Insurance Company NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, P.O. Box 3870 EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Glen Allen, VA 23058-3870 COMPANIES AFFORDING COVERAGE COMPANY CODE SUB-CODE LETTER A MARKEL INSURANCE COMPANY Z COMPANY B �/'3O C INSURED LETTER �t Boys &Girls Club of Capistrano Valley COMPANY m I _ r--' I m 31371 EI Camino RealLF C /F+1 �Ir/JUr `\J � TER San Juan Capistrano, CA 92675 COMPANY O C3 LETTER 'u (Tl COMPANY E LETTER 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 SUN POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY pain rl aim, O POLICY EFFECTIVE POLICY EXPIRATION TR TYPE OF INSURANCE POLICY NUMBER DATE IMM/DD/YY) DATE IMM/DD/YY) UMITS A GENERAL LIABILITY GENERAL AGGREGATE a 3,000,000 X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OPS AGGREGATE $ 1,000,000 CLAIMS MADE EX OCCUR. 8502CY009485-4 11-01-1998 11_01_1999 PERSONAL&ADVERTISING INJURY $ 1,000,000 OWNERS&CONTRACTOR'S PROT. EACH OCCURRENCE $ 1,000,000 FIRE DAMAGE lAny one fire) $ 100,000 MEDICAL EXPENSE(Any one person) $ 5,000 AUTOMOBILE LIABILITY -- COMBINED SINGLE ANY AUTO I a 3 8 ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS 9 NON-OWNED AUTOS GARAGE LIABILITY EXCESS LIABILITY 7 $$ UMBRELLA FORM �( S OTHER THAN UMBRELLA FORM WORKER'S COMPENSATION I O I3o I Q )eo, TS 9 AND EMPLOYERS'LIABILITY ^ a :E $ A OTHER I S! Crime DESCRIPTION OF OPERATIONSA.00ATIONStVEHICLES/SPECIAL ITEMS Certificate holder is included as additional insured for operations conducted by the named insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO City of San Juan Capistrano MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION its officers,agents and employees OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR 32400 Paso A Delano REPRESENTATIVES. San Juan Capistrano, CA 92675 AUTHORIZED REPRESENTATIVE 010 Bruce A. Kay C2i,. VPO ACORD 25-S(7/90) Ic) ACO CORPORATIONr1;990: F SG STATE P.O. BOX 807, SAN FRANCISCO,CA 94101-0807 COMPENSATION INSURANCE FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE POLICY NUMBER: 1381364 - 98 ISSUE DATE: 01-01-98 CERTIFICATE EXPIRES: 01-01-99 CITY OF SAN JUAN CAPISTRANO JOB: 1 . TEEN RECREATION BUILDING b SAFETY DEPARTMENT 2. AFTER-SCHOOL RECREAT. 32400 PASEO ADELANTO EMPLOYEES=2 SAN JUAN CAPISTRANO, CA 92675 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 10 days' advance written notice to the employer. We will also give you 10 days' advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document with respect to which this certificate of insurance 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. 2K PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000.00 PER OCCURRENCE. L a 2 " _n N -v o co EMPLOYER LEGAL NAME BOYS AND GIRLS CLUB OF CAPISTRANO BOYS AND GIRLS CLUB OF CAPISTRANO VALLEY VALLEY (A NON-PROFIT PUBLIC BENEFIT CORP) 31371 EL CAMINO REAL, S J CAPISTRANO, CA 92675 12-18-97 PRINTED: P0408 DOCUMENTTHIS J �� • 11/6/97 6l \ \11•.. \ W015•• 71 Producer 7THISCERTIFIC' ATE IS ISSUED AS A MATTER OF INFORMATION MANION/BELL INSURANCE ASSOCIATES NFERS NO RIGHTS UPON THE CERTIFICATE P.U. BOX 36186 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR LOS ANGELES,CA.90036 iAL1 EH THE COVERAGE AFFORUtU BY THE POLICIES BELOW 38y-5313 COMPANIES AFFORDING'GOVtRAGES LIC.#0655274 Company T insured A MARKEL INSURANCE COMPANY Company - BOYS AND GUU-S CLUB OF CAPISTRA,VO VALLEY 13 31371 EL CAMINO REAL Company ;yt SAN JUAN CAPISTRANO,CA.92675 C Company D THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE ENSURED 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 POLICY LTR TYPE OF INSURANCE NUMBER INCEPTION EXPIRATION LIMITS A x COMM.GENERAL LIABILITY 9502CY009495-3 It/l/97 1 1/1/98 GENERAL AGGREGATE $1,000,000 OCCURRENCE FORM PRODUCTS•COMP/OP AGG $3,000,000 OTHER PERSONAL&ADV INJURY $1,000,000 EACH OCCURRENCE $1,000,000 FIRE DAMAGE(Any one fire) $50,000 (EXCLUDING MEMBERS AND STAFF) MED EXP(Any one person) $5,000 AUTOMOBILE LIABILITY i H AN't AUsO i I I lCOMBINL-U Sl.'*','*-'--::rrl: I ....u:�: •vLR: SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE EXCESS LIABILITY EACH OCCURRENCE UMBRELLA FORM AGGREGATE OTHER THAN UMBRELLA FORM ACCIDENT COVERAGE MED LIMIT PRIMARY SICKNESS EXCESS DEDUCTIBLE DEDUCTIBLE OTHER OTHER DESCRIPTION OF OPERATIONS/LOCATIOPISNEHICLES/SPECUIL ITEMS CERTIFICATE HOLDER IS ADDED AS ADDITIONAL INSURED WITH REGARD TO LIABILITY ARISING OUT OF use of premises. Y:.YJ::•J:: ••• ••'• :••..'Yrwr••..'LY•.:Yr{.r...•};:.yti�:••L•wX{.•,h••L..„,..Ww; ••Li,iSvY.�"«•:•iGYM�:;••r.•_;....L•...M....•....x:x.:.:L.{yVL.J{.h.•.\hL.l.:.{i'.s�rr{.Y..:Y{xL:J.�1.tiJ.Y•.nJ•L....•y�..•Y.frAr.A.L.L'L•LLL;...YL••....`\...LL•WYhL•Jxvh..L.YL•.:.Y•L•LxL.r4YL.��\L:Y.h::•...•xLxY.V.xxf\h.•{LYfYM.h•h:YY.h1•..:�LL�:YL..YAN:..•:Y\.,\••J.J,V}....�xx..x\S�\}.4LaL.�:V..v••..rx.:..'d\YY••:\.LxxYYN.+:.h.'fL•x..L4x'.L�:�: ••,•::{ l•t.: • r'•'• •.;.ti:.•;:;L.,L.Yxw•Y:••Y J•\ L4L :rr.{:\Y\n•A:.}..•:L .4Y;?{MY:}L7:•f.:}:•:v.�\.uyJrtir v•L��}'•.l{:4:v:::•ti:{{�ti:•'vl:}•i.v.i•i:::r=Y}:;:r':.•Y.::i:•k:•:•j:•$:•::•:+. LllLY :0 { • i "010,40% VY • • 4 • : •:••::. .:.. ~•::. .. .,:I JJ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL City of San Juan Capistrano 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, 32400 Paseo Adelanto BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY San Juan Capistrano, CA 92675 OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE --- M ANION / BELL insuranceAssociates NE LICENSE 0655274 October27, 1997 Page 2 Mr. James L.Williams, Executive Director, Boys and Girls Club of Capistrano Valley re: Insurance-Renewal Proposal 2)COMMERCIAL GENERAL LIABILITY INSURANCE Limit of Liability per Occurrence $ 1,000,000.00 General Aggregate(maximum payable during policy term) $ 3,000,000.00 Prod,.sets./Completed Operations per Occurrence $ 1,000,000.00 AND Annual Aggregate $ 1,000,000.00 Fire Legal Liability $ 100,000.00 Premises Medical Payments(excludes Club Members) $ 5,000.00 Sexual Abuse Liability2 Sublimit per person $ 1,000,000.00 aggregate(max. payable during policy term) $ 1,000,000.00 Premium is based on: Loc. 1: 31371 EI Camino Real, San Juan Capistrano Club Building with square footage use of 2,500,with 125 members and additional insured endorsements to various entities for use of property Loc. 2: 32101 Camino Capistrano, San Juan Capistrano Thrift Store with estimated annual receipts of$50,000. additional insured endorsement to Lessor Loc. 3: Loc. 3: 25601 Camino del Avion, San Juan Capistrano, CA(Club) YCLIth Recrea1Wa P Qram with 15 Rapistrants continued 'to continue this coverage you need to 1)run a background check on all employees, (see attached Brochure on CA Hotline) 2)develop a plan of monitoring staff in day to day relationships with members and 3)develop a "Crisis Management Plan"to deal with an incident of abuse. 849 Third Avenue - Los Angeles, CA 90005,- (213)387-8294 - Fax(213)389-5833 Pleave rofpr/n/loo nnlid-V 6IV flnr;nil<•I'%r-"W'V17tv I' I11VIf.r.,I ?V am�rr�ltltinrl.t Page 2 V STATE P.O. BOX 420807,SAN FRANCISCO, CA 94142-0807 COMPENSATION I N S U R A N C E FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE DECEMBER 10, 1997 POLICY NUMBER: 1381364 — 97 CERTIFICATE EXPIRES: 1-1-98 F- CITY OF SAN JUAN CAPISTRANO BUILDING & SAFETY DEPARTMENT 32400 PASEO ADELANTO SAN JUAN CAPISTRANO, CA 92675 JOB: ALL OPERATIONS L This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon ten days'advance written notice to the employer. We will also give you TEN days'advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document with respect to which this certificate of insurance 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. AUTHORIZED REPRESENTATIVE PRESIDENT EMPLOYER' S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1, 000,000 PER OCCURRENCE. 0 rn n _ N � - m W _m N < _ la) M �O D _ CO �J EMPLOYER F- BOYS AND GIRLS CLUB OF CAPISTRANO VALLEY 31371 EL CAMINO REAL SAN JUAN CAPISTRANO, CA 92675 L THIS DOCUMENT HAS A BLUE PATTERNED : • .. ,- ::::; >: ;: . '''`'' ISSUE DATE(MM/DD/YY) Q I ..::...: �:.................:::::..:::., ::::::.::::::..:..:.... :.::.:::::::.::.:::..... 5/20/97 9 / 7 (ODUCERHIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS Markel Insurance Company RE��1v�O IGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, P P.O. Box 3870 ND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. '� 3l}.1 Glen Allen, VA 23058-3870twi COMPANIES AFFORDING COVERAGE C � p x;11 JACtA COMPANY CODE SUB-CODE OF .�* rrER A MARKEL INSURANCE COMPANY • COMPANY B INSURED LETTER Boys&Girls Club of Capistrano Valley COMPANY C 31371 EI Camino Real LETTER San Juan Capistrano, CA 92675 COMPANY D LETTER COMPANY E LETTER r 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 SUN POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY O TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE(MM/DD/YY) DATE(MM/DD/YY) A GENERAL LIABILITY GENERAL AGGREGATE S 3,000,000 X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OPS AGGREGATE $ 1,000,000 CLAIMS MADE OCCUR. 8502CY009485-2 11-01-1996 11-01-�997 PERSONAL&ADVERTISING INJURY S 1,000,000 OWNERS&CONTRACTOR'S PROT. EACH OCCURRENCE $ 1,000,000 FIRE DAMAGE(Any one fire) $ 100,000 MEDICAL EXPENSE(Any one person) $ 5,000 AUTOMOBILE LIABILITY COMBINED SINGLE ANY AUTO LIMIT $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per Person) S HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) S GARAGE LIABILITY PROPERTY DAMAGE S EXCESS LIABILITY EACH OCCURRENCE S UMBRELLA FORM AGGREGATE S OTHER THAN UMBRELLA FORM • 2- :•.r:::•::r:o-:;:r:::•:::t: ::•:<:•:•.:o-:: STATUTORY LIMITS WORKER'S COMPENSATION AND EACH ACCIDENT $ EMPLOYERS'LIABILITY DISEASE-POLICY LIMIT S DISEASE-EACH EMPLOYEE 8 A OTHER Property 8502CY009485-2 11-01-1996 11-01-1997 DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS Certificate holder is included as additional insured as lessor of premises. CERTIFICATE HOLDER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO City of San Juan Capistrano MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION 32400 Paso A Delanto OR LIABILITY OF ANY KIND UPON THE COMPANY, IT AGENTS OR San Juan Capistrano,CA 92675 REPRESENTATIVES. ' V• J i�3 AUTHORIZED REPRESENTATIVE i Bruce A. Kay VPQ` D.25-S(7/90) - (c)ACORD CORPORATION 1990 FWORKErCOMPENSATION INSURANCE PAl`''7LL REPORT COF"IMH3AMONFU N.D �d 1N:ir��w•• Lc 4onnO6138136497. 03nnq 13 g 13Fz( n7o 197100 t 977n97»4 g P.O. BOX 7854 SEP 2919971 SAN FRANCISCO, CA 94120-7854 2 GROUP SG R BOYS AND GIRLS CLUB OF CAPISTRANO POLICY 1381364 - 97 - 3 4 VALLEY 097274 31371 EL CAMINO REAL, PAYROLL PERIOD 7/01/97 TO 10/01/97 7 S J CAPISTRANO, CALIF 92675 104 INSTRUCTIONS: 1.) READ INSTRUCTIONS ON REVERSE SIDE OF THIS REPORT. 2.) If no payroll write "NONE" on all pages. 3.) Sign, date, and return all white pages with payment 4.) Retain yellow copies and have available for audit 111111111111111111111111111111111111111111111111111111 IN 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111VIII1111111111111111111111111111111111111111VIII11111VIIIVIIIVIII1111111111111 SG R 4 BOYS AND GIRLS CLUB OF CAPI S 070197 100197 1381364 97 DESCRIPTION OF WORK DONE PAYROLL OF RATE PREMIUM CODE NO. Add any operations not described below EMPLOYEES Each $100 (Multiply payroll by rate) o Payroll I it ? QVI�ID6 s 10 ?41 &2. 1 . 76 1 1 runt nnl!�� 1 1 1 , 1 , 1 , 1 , t , 1 , }�� crf' cVH111--1 :S 1 ::� v ti r•.� L,111-11 14MAK r u v-0 •,Fr it :� y�• 'v' '�ti r{ •?� 1! YCUR ^":.rC •An!.L i I)IMPTIMc GRncc 4 included above for IBE SUBJECT TO EXCESS - ;PREMIUM ' �7(p ✓�� CANCELLATION `IF ' `Q'`L t Officers, Or working PAYROLL S ' ! I 1 MODIFICATION partners (see exam— THIS REPORT AND ple on reverse). PAYMENT ARE NOT RECEIVED BY 1 t I ENCLOSE CHECK FOR THIS AMOUNT S i CODE NO. DESCRIPTION OF WORK DONE PAYROLL NAME TITLE OR • RELATION S t t t t 1 I(we) certify that the above reported payroll accurately reflects the total wages, salaries, and other compensation paid to all employees (including unlicensed contractors) during the period covered. WILLFUL UNDERREPORTING OF SUCH AMOUNTS IS A VIOLATION OF CALIFORNIA FRAUD STATUTES. SIGNATURE OF PERSON TITLE AREA CODE PHONE NO. PREPARING REPORT 100. NAME AND ADDRESS WHERE PAYROLL RECORDS ARE KEPT (include ZIP CODE) DATE 32400 PASEO ADELANTO + � MEMBERS OF THE CITY COUNCIL SAN JUAN CAPISTRANO,CA 92675 '; J O N G E CAMPBELL (949)493-1171 ,{.y JOHN HART R !� ttlanu[It WYATT HART GIL JONES (949)493-1053(FAX) ' lsutustlt 1961 DAVID M. SWEROLIN 176 DAVID M. CITY MANAGER GEORGE SCARBOROUGH June 17, 1999 Mr. Jim Williams, Executive Director Boys & Girls Club of Capistrano Valley, Inc. 31371 EI Camino Real San Juan Capistrano, California 92675 Re: Renewal of Agreements for After-School Recreation and Teen Programs Dear Mr. Williams: At their meeting of June 15, 1999, the City Council of the City of San Juan Capistrano approved amendments to the After-School Recreation and Teen Program Agreements to extend the term of the Agreements for a one-year period ending June 30, 2000. Fully- executed copies of the two Amendments are enclosed for your files. Thank you for your interest in providing this service to the community. If we can be of further assistance, please let us know. Very truly yours, 4 Cheryl Johnson City Clerk Enclosure cc: Jim Sieger Tony Brown Community Services Director DRUG USE Is AB San Juan Capistrano: Preserving the Past to Enhance the Future � u 1. MOTION TO READ BY TITLE ONLY The Reading of all Ordinances by title only was approved. 2. APPROVAL OF CITY COUNCIL MINUTES OF MAY 18, 199 The Minutes of the Regular Meeting of May 18, 1999, were approved as submitted. 3. RECEIVE AND FILE WARRANTS OF MAY 20 1999 (300 301 The List of Demands dated May 20, 1999,in the total amount of$1,010.718.00,was ordered received and filed. 4. RECEIVE AND FILE INVESTMENTS AS OF MAY 31 1999 (350 30) The City Treasurer's Report of Investments as of May 31, 1999, was ordered received and filed. 5. RECEIVE AND FILE STATUS REPORT OF NEW DEVELOPMENT APPLICATIONS (440.101 The Report dated June 15, 1999, from the Planning Director, advising that one new application had been received since the last Report on May 18, 1999, was ordered received and filed. �T6. RENEWAL OF AGREEMENTS FOR AFTER-SCHOOL RECREATION AND TEEN PROGRAMS(BOYS&GIRLS CLUB OF CAPISTRANO VALLEY INC ) 60( 0.30) As set forth in the Report dated June 15, 1999, from the Community Services Director, the After-School Recreation and Teen Program agreements with the Boys & Girls Club of Capistrano Valley Inc.,were approved extending the terms of the agreements for a one-year period ending June 30, 2000. 7. RENEWAL OF AGREEMENT FOR AFTER-SCHOOL RECREATION PROGRAM SERVICES (CAMP FIRE BOYS & GIRLS. ORANGE COUNTY COUNCIL) (600.30) As set forth in the Report dated June 15, 1999, from the Community Services Director, the After-School Recreation Program and Services Agreement with Camp Fire Boys & Girls, Orange County Council, as amended December 1, 1998 to include a nominal fee of$1 per day to each participant, was extended for a one-year period ending June 30, 2000. City Council Minutes -4- 6/15/99 AGENDA ITEM June 15, 1999 TO: George Scarborough, City Manager FROM: Al King, Jr., Community Services Director SUBJECT: Consideration of Renewal of Agreements for Afterschool Recreation and Teen Programs(Boys& Girls Club of Capistrano Valley, Inc.) RECOMMENDATION: By motion,approve renewal of the Afterschool Recreation and Teen Program agreements between the City of San Juan Capistrano and Boys & Girls Club of Capistrano Valley, Inc. for the period July 1, 1999 through June 30, 2000. SITUATION: A. Background: Current agreements with the Boys&Girls Club of Capistrano Valley to provide afterschool recreation(Attachment A)and teen programs(Attachment B)will expire June 30, 1999. The Boys&Girls Club has been under contract to provide these important youth programs and services to the community since July 1, 1997, for an initial 18-month period,which received a six-month extension in December 1998 through June 30, 1999. B. Summary and Recommendation: The Boys & Girls Club of Capistrano Valley has been providing an increased level of afterschool recreation programs at the existing Boys&Girls Club facility and has been under contract with the City as an afterschool recreation and programs provider since July 1, 1997. This program has been tremendously successful in increasing participation levels as well as broadening program and service offerings to elementary and middle school age youth. Additionally,the Club has also sought to conduct a Friday afterschool teen program at Marco Forster titled "Fabulous Fridays." Difficulties in obtaining qualified staff to conduct this program at Marco Forster Middle School have prevented the program from taking place for much of this current 1998-99 fiscal year. This has resulted in cost savings to the City.The Club and the City are very desirous of Fabulous Fridays taking place during the upcoming fiscal year 1999-2000,and both staff and the Club are recommending the continuation of this program as a part of the contract renewal process. FOR CIN COUNCIL AGEN . .. V � - Agenda Item -2- June 15, 1999 Once the teen program position is filled,the Clubwill resume providing this service with the beginning of the September 1999 school year. Staff is recommending that the City Council approve the renewal of agreements for both the afterschool recreation and Friday afterschool teen programs with the Boys&Girls Club of Capistrano Valley.Terms,conditions,and dollar amounts would remain as currently funded, with the renewed agreements being effective July 1, 1999-June 30, 2000. COMMISSION/BOARD REVIEW,RECOMMENDATION: This item was presented to the Parks,Recreation&Equestrian Commission on May 17, 1999. The Commission recommended unanimously that the City Council approve the renewal. FINANCIAL CONSIDERATIONS: The afterschool recreation program to be conducted at the Boys&Girls Club facility at Serra School is funded as a part of the department's fiscal year 1999-2000 budget request in the amount of $13,868,invoiced monthly from the contractor at$1,155.67. Funding for the Friday afterschool teen program,Fabulous Fridays,has been incorporated in the department's fiscal year 1999-2000 budget request in the amount of$4,217 annually and will be invoiced monthly at a rate of$351.42. These dollar amounts have remained the same, with no projected increase over the term of this renewed agreement. NOTIFICATION: Jim Williams, Executive Director Jim Sieger, Principal Boys & Girls Club of Capistrano Valley, Inc. Marco Forster Middle School 31371 El Camino Real 25601 Camino del Avion San Juan Capistrano, CA 92675 San Juan Capistrano, CA 92675 Tony Brown, President San Juan Community Task Force 31421 La Matanza San Juan Capistrano, CA 92675 Agenda Item -3- June 15, 1999 ALTERNATE ACTIONS: 1. Approve the renewal of the Afterschool Recreation and Teen Program agreements between the City of San Juan Capistrano and Boys & Girls Club of Capistrano Valley, Inc. for the period July 1, 1999 through June 30,2000. 2. Continue the item,and direct staff to return with additional information on specified issues. RECOMMENDATION: By motion, approve renewal of the Afterschool Recreation and Teen Program agreements between the City of San Juan Capistrano and Boys & Girls Club of Capistrano Valley, Inc. for the period July 1, 1999 through June 30, 2000. Respectfully submitted, Al King, Jr. Community Services Director AK:jtb Attachments A. Current Afterschool Recreation Program Agreement with Boys & Girls Club B. Current Teen Program Agreement with Boys&Girls Club C. Amendments to Agreements 0...lwpdocs�45\aiccbg.agm MEMORANDUM December 3, 1997 TO: Dawn Schanderl, Deputy City Clerk FROM: Karen Crocker, Community Services Manager SUBJECT: Boys and Girls Club of Capistrano Valley- Insurance Requirements Attached is a certificate of Liability Insurance and Certificate of Workers' Compensation Insurance. I have contacted the insurance agent directly and she will be including the Capistrano Unified School District on the policy and will be sending us the endorsement form. I am requesting that we take the Boys and Girls Club off the non-pay list, since I anticipate the proper certificates within the next few days. Thank you! LUo►'7&tss elpcPIACOL-1 KC ////'''' MEMBERS OF THE CITY COUNCIL Zp (4 1 F JOECAMPBELL OHNHN GREINER AM mBrroupl WYATT HART uuunrH 1961 GIL JONES 176 DAVID M.SWERDLIN CITY MANAGER GEORGE SCARBOROUGH March 20, 1997 Mr. James L. Williams, Executive Director Boys & Girls Club of Capistrano Valley, Inc. 31371 EI Camino Real San Juan Capistrano, California 92675 Re: After School Recreation Program Dear Mr. Williams: At their meeting of March 18, 1997, the City Council of the City of San Juan Capistrano �CIU� approved agreements with the Boys & Girls Club of Capistrano Valley to provide an after school program Monday-Friday at the club facility for boys and girls ages 6-16; and, to provide a teen program on Fridays at Marco Forster Junior High School for boys and girls in grades 6-8. The Agreements will be effective for an 18-month period beginning July 1, 1979 and ending December 31, 1998. The City has received the required insurance, with the exception of the ViefkeFs-Gtwnpens-dfi-o-n--c—eR-ttrCaWand the liability endorsement form. Please forward those documents to the City Clerk's office as soon as possible. Fully-executed copies of the Agreements are enclosed for your files. Thank you for your interest in providing these services. Please feel free to contact Karen Crocker, Community Services Manager at 443-6389 if you have any questions. Very truly yours, O/Z�9"C_A_ Cheryl Johnson City Clerk Enclosure cc: Karen Crocker vim)/a,�� qFO9 , (71 A) A Q 7 1177 STATE P.O. BOX 420807,SAN FRANCISCO, CA 94142-0807 COMPENSATION IN S U R AN C E FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE 1l E f'L. POLICY NUMBER: CERTIFICATE EXPIRES: 'A TY OF SAN JUAN CAPISTRANO BUILDING & SAFETY DEPARTMENT 32400 PASEO ADELAHTO SAN JUAN CAPISTRANO , CA 92670, JOIs ; AL Ot g Ai 10ra,: L This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon ten days'advance written notice to the employer. We will also give you TEN days'advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document with respect to which this certificate of insurance 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. AUTHORIZED REPRESENTATIVE PRESIDENT E^'PLOYLk ' S LIAGiLITY LiFlil l dt;l Gulru ucFLi1SE COSI yi .UyQ .GUV' ,:'LF, . L a - tE .L EMPLOYER D� f1�.�i: if � lJ�y •'�I BOYS AND GOF CLUB CP,PI& iN .i9 s,: 'f1;.LcY - -- 31371 EL CAMINO REAL SAN JUAN CAPISTRANO, CA 92675 L DOCUMENTTHIS �" "a!'= ' ��, 5�� � '� 3 n Y ��' �y yr ✓"+ T t .. .. ., .w+,-;br r=v b•...Sa.s sm..Y=r.-.. :yyy���r ..(���..Yi .. � r�..je�ry�t � -■^tA 'e+, M " :1ZTAA319"hA k6f. � t � �� N >.� a �} ♦� )T' •Z T"_ '•V S SS '.-- M yr y, .( d a :.-•fit Ye n ii - - 1 �' '3•• _I rY � �! � � � U. _,� �r�,� = f } ,¢_ :V '•�•`,� —1 � ' - IIS"/ � + � s '-yarhTo3.: &t: ri,14 �~�_ • :k v w _ 1 A ZZ y8 t 7 Fr - �•�.+.•e2.p i �',�+�'I:`���1v 1Tz.It �'-,��• • �� n i �t }�;aT�6�in'F.gyF ' h i S I i,Q�s�� ♦l� + 3 � fi � f.l.�• lit- D v X !-r �.._ ��r�� r )ea 2r�.^i • r i >(♦� �s fir.� � AAA 7 V4,. �.. r ,, -•-• . .. Y r� 1�.�L r `"t: 5 :.ren - i `�i•rA A`yr;,� _ . �r. w r.y _ •��'��G .1•. } � "� NF1 Yrf2� f 3 r' _ �'.<u - �� , - . mYr3i./i. STATF. WOWF" - COMPENSATION INSURANCE PAY" `L REPORT COIuVENSATION • `` V �lK ���..�r=.:• iia 4nnn1 6l38136497n3n�r)l-xRi,4Fdnn';,i � . . ► ,977no7?74 w :.�3'_ P.O. BOX 7884 SEP 2 1997 SAN FRANCISCO, CA 94120.7854 IN GROUP SG R BOYS AND GIRLS CLUB OF CAPISTRANO POLICY 1381364 — 97 3 4 VALLEY 097274 31371 EL CAMINO REAL, PAYROLL PERIOD 7/01/97 TO 10/01/97 7 S J CAPISTRANO. , CALIF 92675 104 INSTRUCTIONS: 1.) READ INSTRUCTIONS ON REVERSE SIDE OF THIS REPORT. 2.) If no payroll write 'NONE" on all pages. 3.) Sign, date, and return all white pages with payment 4.) Retain yellow copies and have available for audit 1 IIIA 11111111[111111111111111111111111111 VIII 111111 VIII IIII 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 SG R 4 BOYS AND GIRLS CLUB OF CAPI S 070197 100197 1381364 97 DESCRIPTION OF WORK DONE PAYROLL OF RATE PREMIUM 0 CODE NO. Add any operations not described below EMPLOYEES Each $100 )Multiply payroll by rate) Payroll �1 2 _ 7C L,� •��i/� �a l� 1 �J� �- _ ' . s 1 D F ' b2- 1 . 22 1 1 1 I 1 , 1 1 1 I 1 , I , { .? r,'yrs} { }:S LIIUI.UUL n a.,i Ani,i "N .11 Y fifill-fill 1A r .v :'+mfr' �•• _� .;•::;};. }; J: vn/ n�-/�+ • nl 1 n1/9arlM GRnQq ! a.SJR . ...Y k._._1 included above forBE SUBJECT TO J EXCESS 'PREMIUM ..�.,w�l .1. Ln .1, �....�.....,,........�,L., -�.. officers, or working CANCEL:.ATION 1F "'"" $ h PAYROLL 4 / 1 -MODIFICATION partners (see exam— THIS REPORT AND ple on reverse). PAYMENT ARE NOT RECEIVED BY 1011107 ENCLOSE CHECK FOR THIS AMOUNT $ 1 CODE NO. DESCRIPTION OF WORK DONE PAYROLL NAME TITLE OR • RELATION t 1 I I(we) certify that the above reported payroll accurately reflects the total wages, salaries, and other compensation paid to all employees (including unlicensed contractors) during the period covered. WILLFUL UNDERREPORTING OF SUCH AMOUNTS IS A VIOLATION OF CALIFORNIA FRAUD STATUTES. SIGNATURE OF PERSON TITLE ]AREA CODE PHONE NO. PREPARING REPORT 110. NAME AND ADDRESS WHERE PAYROLL RECORDS ARE KEPT )include ZIP CODE) DATE ISSUE DATE(MM/DD/YY) ACORQR, GER ' � CA�'E NSURANCE _.. .;:. _. 11-14-1997 PRODUCER THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS Markel Insurance Company NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, P.O. BOX 3870 EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Glen Allen, VA 23058-3870 COMPANIES AFFORDING COVERAGE COMPANY A MARKEL INSURANCE COMPANY CODE SUB-CODE LETTER COMPANY 'T INSURED LETTER B c._. Boys&Girls Club of Capistrano Valley COMPANY C =` _ 31371 EI Camino Real LETTER I-,i San Juan Capistrano, CA 92675 COMPANY D _ -_ --. rn LETTER N COMPANY E LETTER - r� A THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE-FOR THE POLICY PERIOD INDICATED, NOTWITHSTANUING 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 0 POLICY EFFECTIVE POLICY EXPIRATION TR TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YY) DATE(MM/DD/YY) LIMITS A GENERAL LIABILITY GENERAL AGGREGATE $ 3,000,000 X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OPS AGGREGATE $ 1,000,000 CLAIMS MADE � OCCUR. 8502CY009485-3 11-01-1997 11-01-1998 PERSONAL&ADVERTISING INJURY $ 1,000,000 OWNERS&CONTRACTOR'S PROT. EACH OCCURRENCE $ 11000,000 FIRE DAMAGE(Any one fire) $ 100,000 MEDICAL EXPENSE(Any one person) $ 5,000 A AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per Person) $ X HIRED AUTOS 8502CY009485-3 11-01-1997 11-01-1998 BODILY INJURY X NON-OWNED AUTOS (Per accident) $ GARAGE LIABILITY PROPERTY DAMAGE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM STATUTORY LIMITS WORKER'S COMPENSATION — - EACH ACCIDENT $ AND DISEASE-POLICY LIMIT $ EMPLOYERS'LIABILITY DISEASE-EACH EMPLOYEE $ A OTHER Property 8502CY009485-3 11-01-1997 11-01-1998 DESCRIPTION OF OPERATIONS/LOCATIONS/VMCLES/SPECIAL ITEMS Certificate holder is included as additional insured as lessor of premises. CERTIFICATE HO`. ...:... ... . . CANC LLATIQN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO City of San Juan Capistrano MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION 32400 Paso A Delanto OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR San Juan Capistrano,CA 92675 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Bruce A. Kay ' ACORD 25'S(7/90) (cl ACORDqflFTRATI0Wj1990 � 1 11/6/97 Producer THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION MANIONBELL INSURANCE ASSOCIATES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O. BOX 36186 HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR LOS ANGELES,CA. 90036 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW (213)387-8294*PAX(213)389-5833 COMPANIES AFFORDING COVERAGES Z LIC.N0655274 COMPWV s Insured A MARKEL INSURANCE COMPAT�F CompFlry BOYS AND GBtIS CLUB OF CAPISTRANO VALLEY B pi 31371 EL CAMINO REAL CompFrry vrM SAN JUAN CAPISTRANO,CA.92675 C ompMry D �� � �!. 't�ia,,,Y��r s_Fav��i�.`1xl MONTI <r���, �,,{Iii� THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD EWE 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 POLICY LTR TYPE OF INSURANCE NUMBER INCEPTION LO@R1Urwx LIMITS A jC0MM.OENE"LUANUTY 9502CYN9495-3 11/1/97 11/1/98 GENERAL AGGREGATE $1,000,000 OCCURRENCE Fovea PRODUCTS'COMP/OP AGG $3,000,000 OTHER PERSONAL&ADV INJURY $1,000,000 EACH OCCURRENCE $1,000,000 FIRE DAMAGE(Any one fire) $50,000 (EXCLUDING MEMBERS AND STAFF) IMED EXP(Any one person) $5,000 AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT ALL OWNED AUTOS BODILY INJURY sCHEDUUOAUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE EXCESS LIABILITY EACH OCCURRENCE UMBRELLA FORM AGGREGATE OTHER THAN UMBRELLA FOAM ACCIDENT COVERAGE MED LIMIT PRMARY SICKNESS EXCESS DEDUCTIBLE DEDUCTIBLE OTHER OTHER OFBCRi1wN OF OFBAATONiA "MNfIVNKCLFe/1FECML ITEMS CERTIFICATE HOLDER IS ADDED AS ADDITIONAL INSURED WITH REGARD TO LIABI rry ARISING OUT OF use of premises. F` . ... :w. Ell x SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WALL ENDEAVOR TO MAIL City of San Juan Capistrano 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, 32400 Paseo Adelanto BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY San Juan Capistrano, CA 92675 OF ANYKINDUPO THECOMPANY,ITS AGENTS OR REPRESENTATIVES. JAUTHORIZED REP "NIATI I e /