2009/05/03 Buxton Company Certificate of Liability Insurance[:f:l�lil�1�1�J
ACORD,. CERTIFICATE
OF LIABILITY INSURANCE
7117/09/DD/YYYY)
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Wortham Insurance & Risk Mgt
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
1600 West Seventh Street
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Fort Worth, TX 76102-2505
817 336-3030
INSURERS AFFORDING COVERAGE
NAIC #
INSURED
INSURERA: Valley Forge Insurance Company
20508
Buxton Company
INSURERS: Continental Casualty Company
20443
2651 S. Polaris Drive
INSURERc: National Fire Insurance Co of H
2O478
Fort Worth, TX 76137
INSURER D:
INSURER E:
COVERAGES
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.
LTR
NSR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE MM/DD/YY
POLICY EXPIRATION
DATE MMID D/YY
LIMITS
A
GENERAL LIABILITY
P2093358583
07/13/09
07/13/10
EACH OCCURRENCE
$1 000 000
X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE F_x1 OCCUR
DAMAGE TO RENTED
PREMISES Ea occurrence\
$300 000
MED EXP (Any one person)
S5 000
PERSONAL & ADV INJURY
$1 000 000
GENERAL AGGREGATE
s2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG
s2,000,000
POLICY F PRO-
JECT LOC
C
AUTOMOBILE
LIABILITY
ANYAUTO
P1079708301
07/13/09
07/13/10
COMBINED SINGLE LIMIT
(Ea accident)
$1 000 000
r ,
X
BODILY INJURY
(Per person)
$
ALL OWNED AUTOS
SCHEDULED AUTOS
X
BODILY INJURY
(Per accident)
$
HIRED AUTOS
NON -OWNED AUTOS
X
PROPERTY DAMAGE
(Per accident)
$
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
S
OTHER THAN EA ACC
$
ANY AUTO
E
S
AUTO ONLY: AGG
B
EXCESS/UMBRELLA LIABILITY
P2093460191
07/13/09
07/13/10
EACH OCCURRENCE
$5 000 000
AGGREGATE
s5,000,000
OCCUR CLAIMS MADE
$
$
HDEDUCTIBLE
$
X RETENTION $ 10000
A
WORKERS COMPENSATION AND
WC2093007771
05/03/09
05/03/10
1 WC STATU- OTH-
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
E.L. EACH ACCIDENT
$1,000,000
E.L. DISEASE - EA EMPLOYEE
$1,000,000
OFFICER/NIEMBER EXCLUDED?
If yes, describe under
SPECIAL PROVISIONS below
YES
E.L. DISEASE - POLICY LIMIT
$1 ,000,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
** Workers Comp Information **
Other States Coverage
Proprietors/Partners/Executive Officers/Members Excluded:
Tom Buxton, Chmn
(See Attached Descriptions)
GtK I It-IGA I t HULUEK GANGELLA7IUN SEE BELOW & PAGE 2
City of Menifee
29714 Haun Road
Sun City, CA 92586
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVE
AUUKU LU (LUV I/Uo) 7 or 3 F577Z37 Z/M7UiSy57 7t3LJli V I-kklu KU I.UKrUKA I IUIV lya8
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.
CANCELLATION NOTICE
The CANCELLATION NOTICE on the CERTIFICATE OF INSURANCE is amended to include the following
wording: The Insurance Companies may cancel the described policy(ies) by mailing or delivering ten (10)
days written notice of cancellation to the Named Insured for: (1) Non Payment of premium or (2) any other
circumstance permitted by state law or policy conditions.
ADDITIONAL INSURED DISCLAIMER
Coverage for Additional Insureds can vary significantly from policy to policy and thus Additional Insured
status does not guarantee protection for all losses. Coverage is subject to actual policy terms and
conditions.
ACORD 25-S (2001108) 2 of 3 #S112312/M108951
uavid Glover, CFO
David Rambie, Exec. V.P.
Todd Walls, Sen. V.P.
Harvey Yamagata, Sen. V.P.
Rich Hollander, President
Tim White, Exec VP
Blanket additional insured Blanket waiver of subrogation coverage is subject to a written contract between
the Named Insured and certificate holder that •requires such status on the General Liability and Auto
Liability. Blanket Waiver of subrogation will apply only to the extent provided by law per any contractual
provision on the Workers Compensation. 30 Day Notice of Cancellation except 10 Day Notice for Cancellation
for Non Pay. Umbrella is follow form to the underlying. Primary and Non Contributory coverage applies to
the General Liability.
AIVIS 25.3 (2001/08) 3 of 3 #S108718/MI08714
DESCRIPTIONS (Continued from Page 1)
David Glover, CFO
David Rambie, Exec. V.P.
Todd Walls, Sen. V.P.
Harvey Yamagata, Sen. V.P.
Rich Hollander, President
Tim White, Exec VP
Additional Insured is added in favor of the Certificate Holder with regards to the General Liability and
Auto Liability. Waiver of Subrogation is added in favor of the Certificate Holder with regard to the
General Liability, Auto Liability, and Workers Compensation. Primary and Non Contributory coverage applies
on the General Liability. 30 Day Notice of Cancellation except 10 Day Notice for Cancellation for Non Pay
in favor of the City of Menifee.
AMS 25.3 (2001/08) 3 of 3 #S112312/M108951