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10-1019_THE OAKS FARM_Insurance OP ID: KV fel �.Jx CERT F �/� 1 E OF LIABILITY INSMNCE DAT 0 10911YYYYj 11 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE 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. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION 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 lieu of such endorsements). PRODUCER 949-365-5100 NAME:CONTACT BrakkeNAME: e##0428915 Ins.Brokers License#F0428975 949-365-5161 PHONE Fax License IA C,Na,Ext): _ - LAIC,Not: 28202 Cabot Road,Suite 600 E-MAIL Laguna Niguel,CA 92677-1251 PRODUCER John Riordan CUSTOMER,,,:OAKSI-1 �— ___- INSURER(S)AFFORDING COVERAGE NAIC# INSURED The Oaks, Inc. � INSURER A:The Travelers Indemnity Co. P.O. Box 9453 INSURER B:Topa Insurance Company San Juan Capistrano,CA 92675 INSURER C: INSURER D; ..m._..-___ ._..�...._.., �__._.._. INSURER E INSURER F: ._...,__.....,.... ......_.__ 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 DESCRIBED HEREIN €5 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN5R TYPE OF INSURANCE __.-..._ ADDL SUHR POLICY EFF POCY EXP LTR POLICY NUMBER MMIDDIYYYY LIMMIDDIYYYY LIMITS GENERAL LIABILITY I EACH OCCURRENCE $ 1,000,00_0 A X COMMERCIAL GENI RAI L[ABILIY 700$36©W121TCT71 0610$171 06/09112 AMA E T RENT-. PREMISESEa occurrence $ 100,00 CLAIMS-MADE _I OCCUR � MED EXP(Any one person} *"� .__.._-.— 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 HGEN1 AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP A $ 2,000,00 POLICY[ PRO- LOC GG $ -__ AUTOMOBILE LIABILITY € COMBINED SINGLE LIMIT C"7 ( (Ea accident)__.___._-_. $ _..,,......,.__.....� ANY AUTO BODILY INJURY(Per person) $ AL1.OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS --PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS I - UMBRELLA LIAR X OCCUR I EACH OCCURRENCE $ 5,000,00 X EXCESS LIAR CLAIMS-MADEJ AGGREGATE -. $ -- XL6603039 f 05!09111 06/09112 __..__.__ DEDUCTIBLE f g RETENTION WORKERS COMPENSATION I TVJG STATU- 0TH- AND EMPLOYERS'LIAR€LITY YIN ORY LIMIT, R ANY PROPRIETORIPARTNEWEXECUTiVE OFF€CERIMEMBER EXCLUDED? ❑ N i A E.L.EAChI ACCIDENT (Mandatory to NH) E.L.DISEA$7 EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEA POLI YPUJITJ $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach 1ACORD 101,AddMgnat Remarks Schedule,If more space Is required) ffi .r The City of San Juan Capistrano is named as additional insured per the 4 attached endorsement CG2024 , c ; CERTIFICATE HOLDER CANCELLATION Cis I CITYSJC SHOULD ANY OF THE ABOVE DESCRIBE POLICIUBE CANCELLED BEFORE City of San Juan Capistrano THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Manager ACCORDANCE WITH THE POLICY PROVISIONS. 32400 Paseo Adelanto San Juan Capistrano,CA 92675 AUTHORIZED REPRESENTATIVE YD 1 cO 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 26(2009109) The ACORN name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY POLICY DUMBER: 700-836OW1 21 -TCT-11 ISSUE DATE: o5--1 1 -1 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CARE-FULLY. ADDITIONAL INSURED - OWNERS OR OTHER INTERESTS FROM WHOM LAND HAS R I::N LEASED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designation of Premises (Part Leased to You): CORNIER OF ASSESSOR'S P#125--172--07 SAID JUAN CAPISTRANO CA 92475 Name of Person or Organization; CITY OF SAN JUAN CAPISTRANO 32400 PASEO AOELANTO SAN JUAN CAPISTRANO CA 92675 (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 This insurance does not apply to °^ include as an insured the person or organization 1. Any "occurrence" which takes place after you shown in the Schedule but only with respect to cease to lease that lane:; liability arising out of the ownership, maintenance or ® use of that part of the land leased to you and shown 2. Structural alterations, new construction or — in the Schedule and subject to the following addition- demolition operations performed by or on behalf of exclusions: of the person or organization shown in the w Schedule. CG 20 24 11 85 Copyright, Insurance Services Office, Inc., 1984 Page 1 of 1 oiaaas