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02-0815_ROMAN CATHOLIC BISHOP OF ORANGE_Insurance ComplianceClient#: 1502 CATHORA ACOgD™ CERTIFICATapF LIABILITY INSUR^CE JST"^ RODUCER ^ jrthur J. Gallagher & Co. Ins. r\ /Ofl I irokersof CAIncLic.#0726293f //.({J . ,*/ ( VlfgAk T .ne Market Spear TwrSte 200 (JP^lpUL an Francisco, CA 94105 KJ<.(_J THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ^ HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR j#fTERTHE COVERAGE AFFORDED BYTHE POLICIES BELOW. RODUCER ^ jrthur J. Gallagher & Co. Ins. r\ /Ofl I irokersof CAIncLic.#0726293f //.({J . ,*/ ( VlfgAk T .ne Market Spear TwrSte 200 (JP^lpUL an Francisco, CA 94105 KJ<.(_J INSURERS AFFORDING COVERAGE NAIC# SURED Roman Catholic Bishop of Orange, etal PC Box 14195 Orange, CA 92863 iNSURERA: The Ordinary Mutual 10171 SURED Roman Catholic Bishop of Orange, etal PC Box 14195 Orange, CA 92863 INSURERS: United States Fidelity and Guaranty 25887 SURED Roman Catholic Bishop of Orange, etal PC Box 14195 Orange, CA 92863 INSURER C: SURED Roman Catholic Bishop of Orange, etal PC Box 14195 Orange, CA 92863 INSURER D: SURED Roman Catholic Bishop of Orange, etal PC Box 14195 Orange, CA 92863 INSURER E: OVERAGES 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 BYTHE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. R W3D' I NSRI TYPE OF INSURANCE POUCY NUMBER POUCY EFFECTIVE DATE IMM/DD/YYt POUCY EXPIRATION DATE IMM/DD/YY) UMITS GENERAL UABIU TY L GENERAL LIABILITY CGAL0042004 07/01/04 07/01/05 EACH OCCURRENCE $1,000,000 COMMERCIA TY L GENERAL LIABILITY CGAL0042004 07/01/04 07/01/05 DAMAGE TO RENTED PREMISES lEa occurrence! $50,000 CLAIMS MADE X OCCUR CGAL0042004 07/01/04 07/01/05 MED EXP (Any one person) $5,000 CGAL0042004 07/01/04 07/01/05 PERSONAL &ADV INJURY $1,000,000 CGAL0042004 07/01/04 07/01/05 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: CGAL0042004 07/01/04 07/01/05 PRODUCTS - COMP/OP AGG $2,000,000 POLICY PRO- „ , -„ JECT X LOC CGAL0042004 07/01/04 07/01/05 AU- X rOMOBILE UABIUTY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS CGAL0042004 07/01/04 07/01/05 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 rOMOBILE UABIUTY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS CGAL0042004 07/01/04 07/01/05 BODILY INJURY (Per person) $ rOMOBILE UABIUTY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS CGAL0042004 07/01/04 07/01/05 BODILY INJURY (Per accident) $ rOMOBILE UABIUTY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS CGAL0042004 07/01/04 07/01/05 PROPERTY DAMAGE (Per accident) $ CGAL0042004 07/01/04 07/01/05 PROPERTY DAMAGE (Per accident) $ GARAGE UABIUTY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHEPTHAN ^^^^^ $ ANY AUTO AUTO ONLY: ^^qq $ EXCESSAJMBRELLA UABIUTY 1 EACH OCCURRENCE $ i OCCUR CLAIMS MADE 1 AGGREGATE $ 1 $ DEDUCTIBLE RETENTION J 1 s DEDUCTIBLE RETENTION J 1 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRierOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below D215W00004 11/13/03 11/13/04 ^ WC STATU- OTH-X TORY LIMITS ER WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRierOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below D215W00004 11/13/03 11/13/04 E.L. EACH ACCIDENT $1,000,000 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRierOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below D215W00004 11/13/03 11/13/04 E.L, DISEASE - EA EMPLOYEE $1,000,000 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRierOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below D215W00004 11/13/03 E.L. DISEASE-POLICY LIMIT | $1,000,000 OTHER 5CRIPTI0N OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS E: Catholic Charities of Orange County, Inc., 1800 E. McFadden Ave., inta Ana, CA 92705 as respects lease of Stonefield Community lilding/OfRce. City of San Juan Capistrano is Additional Insured. RTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE /VBOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION City of San Juan Capistrano DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 7,^ DAYS WRITTEN Attn: Community Services Dept. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL 25925 Camino del Avion IMPOSE NO OBUGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR San Juan Capistrano, CA 92675 REPRESENTATIVES. San Juan Capistrano, CA 92675 AUTHORIZED REPRESENTATIVE / ORD 25 (2001/08) 1 of 2 #M123823 KXS © ACORD CORPORATll^1988 • • POLICY NUMBER: CGALO042004 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES or CONTRACTORS (FORM B) This endorsement modifies insurance provided under the foilowing: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: City of San Juan Capistrano Attn: Community Services Dept. 25925 Camino del Avion 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 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. IE: Catholic Charities of Orange County, Inc., 18 0 0 E. McFadden Ave., 3anta Ana, CA 92 705 as respects lease of Stonefield Community 5uilding/0f f ice. City of San Juan Capistrano is Additional Insured. IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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 endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. 32400 PASEO ADELANTO SAN JUAN CAPISTRANO, CA 92675 (949)493-1171 (949) 493-1053 FAX WWW. sanjuancapistrano. org MEMBERS OF THE CITY COUNCIL SAMALLEVATO DIANE L. BATHGATE WYATTHART JOE SOTO DAVID M. SWERDLIN June 3, 2004 Catholic Charities of Orange County, Inc. 1800 E. McFadiJen Avenue Santa Ana, CA 92705 RE: Compliance with Insurance Requirements - Use of Stone Field Community Building: V General Liability Certificate 7/1/2004 ? V General Liability Endorsement Form naming Capistrano as additional insured. tl^^^itv City of San Juan Please submit upc^ted documentation to the City of San Juan Capistrano, attention City ds office, 32400 Paseo Adelanto, San Juan Capistrano, CA 92675 by the above atiopi itlatei. If Vou have any questions, please contact me at (949) 443-6309. Mar ecretary cc: Karen Crocker, Community Services Manager San Juan Capistrano: Preserving the Past to Enhance the Future