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Home My WebLink AboutMISCELLANEOUS INSURANCES 1965-68 ACIFIC INDEMNITY COMP"AY CERTIFICATE OF INSURANCE • CITY OF HUNTINGTON BEACH ATTN: MR. PAUL JONES • CITY HALL CITY CLERK • HUNTINGTON BEACH, CALIFORNIA THIS IS TO CERTIFY as to the existence as of this date of the below described insurance with the Pacific Indemnity Company. Should any change occur in this insurance, the undersigned will endeavor to give written notice to the holder of this certificate, but failure to give such notice shall impose no obligation or liability upon the company or the undersigned. Name of Insured LIONS CLUB OF HUNTINGTON BEACH, INC. Address of Insured P. 0. BOX 62, HUNTINGTON BEACH, CALIFORNIA Location of Risk STATE OF CALIFORNIA Description of Risk SERVICE CLUB BANNER 25 FEET LONG, 3 FEET WIDE, OVER NORTH MAIN ST. AT llth STo Workmen's Compensation: Policy No. Term: from �} to Comprehensive Liability: Policy No. LAG' 194895 Term: from 7-3-68 to 7-3-71 Comprehensive General Liability Insurance: Bodily Injury Liability $ 100,000.00 each person. $ 300,000.00 each occurrence. $ 300,000.00 aggregate. Property Damage Liability $ 50,000.00 each occurrence. $ 50 9 000.00 aggregate. Comprehensive Automobile Liability Insurance: Bodily Injury Liability $ 100,000.00 each person $ 300,000.00 each occurrence Property Damage Liability $ 50,000.00 each occurrence Owners', Landlords' and Tenants' Liability: ❑ Policy No. Manufacturers' and Contractors' Liability: ❑ Term: from to Bodily Injury Liability $ each person. $ each occurrence. Property Damage Liability $ each occurrence. $ aggregate. Policy No. Term: from to This Certificate of Insurance neither affirmatively or negatively amends, extends or alters the coverage afforded by any of the above mentioned policies. Yf 1s agreed fhaif Ae above numbered pogcy for proliclesT may not be cancelled by the Company until the Company REMARKS: has mailed writte- - named Certificate Holder stating w' ess f+an TEN (10` DAYS thereafter, such c aiior• snail be effective. Delivery of such wriffen notice by the Company shall be equivalent to mailing.} Certified this 18th day of JUNE 19 68 JONES—GILLESPIE & GOPPERT, INC. AJS:MW BYE; B l Y Form M0058c (468) r o- ACIFIC INDEMNITY 00MRAY CERTIFICATE OF INSURANCE ~ G a CITY OF HUNTINGTON BEACH ATTN: MR. PAUL JONES, CITY HALL CITY CLERK x HUNTINGTON BEACH, CALIFORNIA tz THIS IS TO CERTIFY as to the existence as of this date of the below described insurance with the Pacific Indemnity Company. Should any change occur in this insurance, the undersigned will endeavor to give written notice to the holder of this certificate, but failure to give such notice shall impose no obligation or liability upon the company or the undersigned. Name of Insured LIONS CLUB OF HUNTINGTON BEACH, INC. Address of Insured P. 0. BOX 62, HUNTINGTON BEACH, CALIFORNIA Location of Risk STATE OF CALIFORNIA Description of Risk SERVICE CLUB BANNER 25 FEET LONG, 3 FEET WIDE, OVER NORTH MAIN ST. AT 11th ST. Workmen's Compensation: Policy No. Term: from to Comprehensive Liability: Policy No. LAC 191227 Term: from 7-3-67 to 7-3-68 Comprehensive General Liability Insurance: Bodily Injury Liability $ 100,000,00 each person. $ 300,000,00 each occurrence. $300,000.00 aggregate. Property Damage Liability $ 50,000,00 each occurrence. $ aggregate. Comprehensive Automobile Liability Insurance: Bodily Injury Liability $ 100 t 000,00 each person $ 300,000-00 each occurrence Property Damage Liability $ 50,000.00 each occurrence Owners', Landlords' and Tenants' Liability: ❑ Policy No. Manufacturers' and Contractors' Liability: ❑ Term: from to Bodily Injury Liability $ each person. $ each occurrence. Property Damage Liability $ each occurrence. $ aggregate. Policy No. Term: from to REMARKS: It is '0greed that the above numbered policy for patiries) tray not be cancelled by the Company until the Compary has mailed written rctico to tiie a,,ove ,rr^e: Ce:`;(iCe:e Holder stating when. h:.,t nn- 1,,, •('^} fherrafh:4, suc1, c+rteJF,;_r Ue bt iif, r,,.ih�rr r;yq,cp by We Umgany shall be equivataat to nja.�E:,y, th Certified this 5 + day of JUNE 19 67 AJS:DY JONES-GILLESPIE, INC. J-- - GILLESPIE N By B Form M0058b 250M 1266 h o o oI ampP, CERTIFICATE OF INSURANCE>,„' SUPERSEDING CERTIFICATE ISSUED MAY-$, 19,67, 7_ 5_ G 2 I CITY OF HUNTINGTON BEACH ATTN::,m.M=R. PAUL JONES, • CITY HALL ..CrTTY-,CLERK • HUNTINGTON BEACH, CALIFORNIA THIS IS TO CERTIFY as to the existence as of this date of the below described insurance with the Pacific Indemnity Company. Should any change occur in this insurance, the undersigned will endeavor to give written —notice to the holder of this certificate, but failure to give such notice shall impose no obligation or liability upon the company or the undersigned. Name of Insured LIONS CLUB OF HUNTINGTON BEACH, INC. Address of Insured P. 0. BOX 62, HUNTINGTON BEACH,CALIFORNIA Location of Risk STATE OF CALIFORNIA Description of Risk SERVICE CLUB BANNER 25 FEET LONG, 3 FEET WIDE, OVER NORTH MAIN ST. AT 11TH ST. Workmen's Compensation: Policy No. Term:from to Comprehensive Liability: Policy No. LAC 178294 Term:from 7-3-66 to 7-3-67 Bodily Injury Liability $ 100,000. each person. $ 300,000, each occurrence. $ 300,000..aggregate. Property Damage Liability—Automobile $ 50,000. each accident. Property Damage Liability—Except Automobile $ 50,000. each accident. $ 50,000. aggregate. Owners', Landlords' and Tenants' Liability: ❑ Policy No. h anufacturers' and Contractors' Liability: ❑ Term:from to Bodily Injury Liability $ each person. $ each accident. $ aggregate. Property Damage Liability $ each accident. $ aggregate. Policy No. Term:from to It Is agreed that the above numbered policy (or policies) may r•.'ot bs cancelled by the company iiniii"I Crmpany REMARKS: SEE ENDORSEMENT #6 ATTACHED, has mailedwritt�n notice to the above nar.tcfl eo_rtiticnte Helder 'statinq when, but net less than 1+fIRTY (3A) DAYS thereafter, such cancellation shall be effective. Delivery of such written notice by the Company shall be equivalent to mailing. Certified this 19th day of MAY 19 — r JONES—GILLESPIE, INC. BH:EW By B r V Form M 0058a 250M 8-66 No. g A.P. In eons tIan *f *a AdAfttloval Premium of TU AND * DOERS ( 10. ), It is r*e t t th* CM QF XMI to an Additioval Insured der the polivy BUT ONLY WIN RWICT to the existameofa95x3tt. banmw *VW North x"A st, at 11tbt t*0 u 1 "* cal?fors l►. XWO1 =MR SzCTIU* a OF Tu SURM Awl This endorsement forms a part of the policy to which it is attached, and is effective from the inception date of the policy unless an effective date is shown below. (Complete following spaces when this endorsement is not attached at time policy written.) C I' n4 of PACIFIC INDEMNITY COMPANY XAT 8#196T POLICY NUMBER EFFECTIVE DATE do 0, um 11 SUCH a, I=• INSUREDl�, DAT..F ISSUE JOK=!L7,WPU"01F 0,D, 7- � ORIZED REPRESENTATIVE Form 1A026a 300M 566 DO NOT USE THIS SPACE—FOR HOME OFFICE USE ONLY LINE KIND BRKGE STATE CITY CLASS LINE GROSS PREMIUM GROSS PREM.CANC'D COMM.RATE i I CERTIFICATE OF INSURANCE CITY OF HUNTINGTON BEACH CITY HALL HUNTINGTON BEACH, CALIFORNIA ATTN: MR. PAUL JONES, CITY CLERK THIS IS TO CERTIFY as to the existence as of this date of the below described insurance with the Pacific Indemnity Company. Should any change occur in this insurance, the undersigned will endeavor to give written _notice to the holder of this certificate, but failure to give such notice shall impose no obligation or liability upon the company or the undersigned. Name of Insured LIONS CLUB OF HUNTINGTON BEACH, INC. Address of Insured P. 0. Box 62 Location of Risk HUNTINGTON BEACH, CALIFORNIA Description of Risk SERVICE CLUB BANNER 25 FEET LONG, 3 FEET WIDE, OVER NORTH MAIN ST. AT 11TH ST. Workmen's Compensation: Policy No. Texm:from to Comprehensive Liability: Policy No. Term:from to Bodily Injury Liability $1009 000.0.0 each person. $3009,000,09ach occurrence. $ 509 OOO.Ogggregate. Property Damage Liability—Automobile $ 50,000.04ach accident. _Property Damage Liability—Except Automobile $ 50,000.OQach accident. $ 509 000.OQggregate. Owners', Landlords' and Tenants' Liability: ❑ Policy No. Manufacturers' and Contractors' Liability: ❑ Term:from to Bodily Injury Liability $ each person. $ each accident. $ aggregate. Property Damage Liability $ each accident. $ aggregate. Policy No.LAC178294 Term:from 7/3/66 to 7/3/67 REMARKS:IT IS AGREED THAT SUCH INSURANCE AS IS AFFORDED BY THIS POLICY SHALL APPLY TO THE CITY OF HUNTINGTON BEACH, ITS OFFICERS EMPLOYERS AND AGENTS AS ADDITIONAL INSURED UNDER THIS POLICY. IT IS FURTHER AGREED THAT 30 DAYS CANCELLATION NOTICE THEREAFTER SHALL BE EFFECTIVE WITH PROPER NOTICE TO THE CITY OF HUNTINGTON BEACH. Certified this 8th day of MAY 19�. JONES— ILLESPIE, INC. By - Form M0058a 350M 963 ON ,,1e'. fir' C City of Huntington Beach K DALE. BUSH ,* CI7Y ATTORNEI PAUL C. JONES „os. P.O. BOX 190 CALIFORNIA 92648 CITY CLERK C �� BETTY DIEKOF'F COUNTY Y TREASURER DOYLE MILLER COUNCILMEN ADMINISTRATIVE JAKE R STEWART MAYOR OFFICER TED W BARTLETT BRANDER D. CASTLE ALVIN M COEN ASSISTANT ERNEST H. GISLER ADM'.NISTRATOR N JOHN V V GREEN (� �7 DR HENRY S KAUFMAN May 5, 176/ DR DONALD D. SH:PLEY Mr. Jack Cleveland, Pro)'ect Chairman Huntington Beach Lions Club Huntington Beach, California Dear Mr. Cleveland: Your request for permission for the Huntington Beach Lions Club to use the Lake Park clubhouse and cookingg facilities on Saturday, May 13, 1966 from 6:00 A.M. to 1:00 P.M. for your annual fund- raising breakfast is hereby granted. Permission to hang your banner over Main Street at the entrance to the park is also granted subject to your furnishing the City Clerk a certificate of insurance for property damage and public liability in the amounts of $25,000 and $50,000 and $50,000 for each occurrence, naming the city as jointly insured with the Lions Club. It is under- stood that the banner will be installed by a city crew on Friday, May 5, and will be removed Monday, May 15. It will be necessary for you to deliver the banner to the city yard for installation. Sincerely, Doyle Miller City Administrator DM:bwo CC: City Council Director of Public Works City Clerk JAMES R. WHEELER DELBERT G. HIGGINS DIRECTOR OF PUBLIC WORKS FIRE CHIEF KENNETH A. REYNOLDS FRANK B. ARGUELLO PLANNING 1,IRECTOA VINCENT G MOORHOUSE FINANCE DIRECTOR LIFEGUARD CHIEF NORM WORTHY j; JOHN SELTZER RECREATION a OLLIN C CLEYELAND POLICE CHIEF PARKS DIRECTOR BUILDING DIRECTOR r" cD FiJIFIC INDEMNI1Y CDMPL11 CERTIFICATE OF INSURANCE O M • CITY OF HUNTINGTON BEACH, ITS OFFICERS & DIRECTORS AS ADDITIONAL g . FIFTH & ORANGE STREETS INSUREDS cv . HUNTINGTON BEACH, CALIFORNIA THIS IS TO CERTIFY as to the existence as of this date of the below described insurance with the Pacific Indemnity Company. Should O e� any change occur in this insurance, the undersigned will endeavor to give written notice to the holder of this certificate, but failure to give such notice shall impose no obligation or liability upon the company or the undersigned. !n O M Name of Insured LEAGUE OF WOMEN VOTERS OF HUNTINGTON BEACH, INC. Address of Insured 17041 COURTNEY LANE Location of Risk HUNTINGTON BEACH, CALIFORNIA Description of Risk OWNER's, LANDLORD'S & TENANT'S LIABILITY Workmen's Compensation: Policy No. Term: from to Comprehensive Liability: Policy No. Term: from to Comprehensive General Liability Insurance: Bodily Injury Liability $ each person. $ each occurrence. $ aggregate. Property Damage Liability $ each occurrence. $ aggregate. Comprehensive Automobile Liability Insurance: Bodily Injury Liability $ each person $ each occurrence Property Damage Liability $ each occurrence Owners', Landlords' and Tenants' Liability: EX Policy No. LG 96374 Manufacturers' and Contractors' Liability: ❑ Term: from 11-1-67 to 11-1-70 Bodily Injury Liability $50,000♦00 each person. $ 1009000000 each occurrence. Property Damage Liability $ 259 000.00 each occurrence. $ aggregate. Policy No. Term: from '' to REMARKS: Certified this � day of 00T0B 'FN 19 6r7 JONES—GILLESPIE & GOPPERT, INC. Y Form M00586 250M 1266 G 109 No. ADDITIONAL INSURED A.P. (Premises Leased to the Named Insured) R.P. r Itis endorsement modifies such insurance as is afforded by the provisions of the policy relating to the following: 1r' COMPREHENSIVE GENERAL LIABILITY INSURANCE ` MANUFACTURERS' AND CONTRACTORS' LIABILITY INSURANCE �✓` OWNERS', LANDLORDS' AND TENANTS' LIABILITY INSURANCE STOREKEEPER'S INSURANCE SCHEDULE Premiums Bodily Property Injury Damage Designation of Premises Name of Person or Organization Liability Liability (Part Leased to Named Insured) (Additional Insured) *NAM ST* am or WAM sr • " 6 0111311,10M at It is agreed that the "Persons Insured" provision is amended to include as an insured the person or organization designated above,but only with respect to liability arising out of the ownership, maintenance or use of that part of the premises designated above leased to the named insured, and subject to the following additional exclusions: The insurance does not apply: 1. to any occurrence which takes place after the named insured ceases to be a tenant in said premises; 2. to structural alterations, new construction or demolition operations performed by or on behalf of the person or organization designated above. This endorsement forms a part of and is for attachment to the following described policy issued by the PACIFIC INDEMNITY COMPANY and is effective from the inception date of the policy unless another effective date is shown below. MUST ALWAYS COMPLETE ONLY WHEN THIS ENDORSEMENT IS NOT PREPARED WITH THE POLICY OR IS NOT TO BE EFFECTIVE FROM THE INCEPTION BE COMPLETED DATE OF THE POLICY. POLICY NUMBER INSURED DATE OF ISSUE EFFECTIVE DATE OF THIS ENDORSEMENT LINE KIND COI M BR OFF. AGENT DO NOT USE THIS SPACE FOR HOME OFFICE USE ONLY P.UTHORIZED REPRE SENTM'T1VE=+'I�'� POLICY EXPIRATION T TAX COMM. R STATE CITY CLASS D EXPOSURE CAR LINE PREM.WRITTEN PREM CANCELED LOC. RATE MO. YR. MO. YR. MOS. M I I I I I I I I I I I Form 1 C058 1 OM 767 THE TRAVELWHO Vista Insurance Agency Certificate of Insurance 1717 SOUTH BROOKHURST ST. ' ANAHEIM, CALIFORNIA 92804 ��RR v o t This is to certify that policies of insurance as described below have been issued �ie ed named below and are in force at this time. If such policies are canceled or changed during the periods of coverage as stated H herein, in such a manner as to affect this certificate, written notice will be mailed to the party designated below . for whom this certificate is issued. A 1. Name and address of party to whom this certificate is issued 2. Name and address of insured _CITY OF HUNTINGTON BEACH LUXURY HOMES , INC. , ETAL CITY HALL 905 NO. EUCLID HUNTINGTON BEACH, CALIFORNIA ANAHEIM, CALIFORNIA L J 3. Location of operations to which this certificate applies ALL OPERATIONS 4. Coverages for which insurance is afforded Limits of Liability Policy Number Policy Period* i. Workmen's Compensation and Employers' Compensation—Statutory ** Liability in the state named in item 3 hereof DKUB2200982 7/1/67 to 7/1/68 Bodily Injury Liability—except automobile ** $ each person cluding Protective $ each accident - - - -- - - - --------------------"----------------------------------------** Property Damage Liability—except automobile �# $ each accident cluding Protective $ aggregate ** Bodily Injury Liability—automobile $ each person $ each accident ------------------------------------------------------------------ -------------------------------------------- ** Property Damage Liability—automobile $ each accident ** Liability (Bodily Injury and Property Damage) $ each accident *Policy is effective and expires at 12:01 A.M., standard time at the address of the named insured as stated herein. **Absence of an entry in these spaces means that insurance is not afforded with respect to the coverages opposite thereto. Description of Operations, or Automobiles to which the policy applies: r The insurance afforded is subject to all of the terms of the policy, including endorsements, applicable thereto. THE TRAVELERS INSURANCE COMPANY Office SANTA ANA, CALIFORNIA THE TRAVELERS INDEMNITY COMPANY THE CHARTER OAK FIRE INSURANCE COMPANY Producer ORANGE VISTA IM URANCE AGENCY =M.SITA INSURANCE AGE Date 6/28/67 OV/1r $ C-5918 REV.10-65 PRINTED IN U.S.A. Authorize presentative R Effective from at the time of day the policy becomes effective. Amending Policy No.DKUB2200982 Issued to Date of Issue: 6-6-67 OFFICE PROD. PROD, FOR 6 CODE CODE Co.E POL, MODE OF LOG.OF EXPIRES ADJUST. RISK (The information provided for above,except the policy number,is required to be stated only when this endorsement is issued for attachment to the policy subsequent to its effective date.) It is agreed that as of the effective date hereof the policy is amended in the following particulars: THE CITY OF HUNTINGTON BEACH IS HEREBY NAMED AS AN ADDITIONAL ASSURED BUT ONLY AS RESPECTS TO EMPLOYEES HIRED BY AND INCLUDED ON THE PAYROLL OF LUXURY HOMES INC AND SUNNY HILLS SALES INC. 8000(D) This endorsement is executed on the reverse side hereof. SYMBOL No. THE TRAVELERS INSURANCE COMPANY THE TRAVELERS INDEMNITY COMPANY THE CHARTER OAF.FIRE INSURANCE COMPANY Secretary Se�E VISTA INSJR�RA;ICE EtJCY Secretary C-10747 (Small) 2-65 PRIN7E13 IN U.S.A. Countersigned by CERTIFICATE BAI BOA-ARROWHEAD GROUP A [3� BALBOA INSURANCE COMPANY OF INSURANCE SIB W. . ', STREET LOS ANGELUS 17. CALIF. ❑ ARROWHEAD INSURANCE COMPANY< TO: • DATE JULY 15, 1965 0 CITY CLERK CITY OF HUNTINGTON BEACH 9 HUNTINGTON BEACH, CALIFORNIA (D Z ct • This is to certify that the Company or Companies checked above have in force as of the date hereof the following policy or policies: fD NAME AND ADDRESS OF INSURED OR EMPLOYER LOCATION OF PROPERTY, DESCRIPTION OF OPERATIONS, BUSINESS CONDUCTED cif MIDWAY EQUIPMENT RENTALS 14141 HUNTINGTON BEACH BOULEVARD WESTMINSTER, CALIFORNIA I (D H KIND OF INSURANCE POLICY NUMBER EXPIRATION LIMITS OF LIABILITY 1- BURGLARY $ t-4 GLASS Replacement BODILY INJURY LIABILITY Other Than Automobile* 100 thousand dollars, each person PF 10113 7/15/68 300 thousand dollars, each accident 300 thousand dollars, aggregate products PROPERTY DAMAGE Liability other than Automobile' 25 thousand dollars, each accident 25 thousand dollars, aggregate operations it 25 thousand dollars, aggregate protective 25 thousand dollars, aggregate products 25 thousand dollars, aggregate contractual AUTOMOBILE: 100 Bodily Injury Liability* �� i� 3a� thousand dollars, each person thousand dollars, each accident Property Damage Liability* 25 thousand dollars, each accident Medical Payments $ each person Comprehensive—Loss of or Damage to the Actual Cash Value Unless Otherwise State Herein Automobile, Except by Collision or Upset but including Fire, Theft and Windstorm $ Collision or Upset Actual Cash Value less $ deductible Actual Cash Value Unless Otherwise Stated Herein Fire, Lightning and Transportation Theft (Broad Form) $ Year Trade Name Body Type Serial or Motor Number Schedule Additional Automobiles on ALL OWNS $ NON-OWNED AND HIRED AUTOMOBILES. Reverse Side. ALL-OPERATIONS OF THE I SURED INCLUDING COMPLETED OPERAITIONS OR PRODUCTS. Special Conditions or Coverages 7 JACK C. TEN DAYS NOTICE WILL BE GIVEN IN EVENT OF CANCELLATION. INSURANCE UNiversity •• . • , CAL]IF.A, •If Comprehensive, so state. If not Comprehensive, for "other than Auto," list form such as OLT, ELEV., etc. C. In event of any material change in or cancellation of the policy or policies, the Company insurance Agency, will make every effort to notify the addressee but undertakes no responsibility by reason of failure to do so. By r-.�- — — ------- ------------------ CRT I (ED. 2-62) 26M 2-62 Authorized Represents e CERTIFICATE Ba1.B0A-ARR0WHE A,,D GROUP A U BALBOA INSURANCE COMPANY OF INSURANCE SIB W. rY14 STREET LOS ANGELES 17. CALIF. ❑ ARROWHEAD INSURANCE COMPANY TO: �•-` • CITY CL�tK DATE NOVEKBER 20, 1964 CITY OF HUNTINGTON BEACH HUNTINGTON BEACH, CALIFORNIA • This is to certify that the Company or Companies checked above have in force as of the date hereof the following policy or policies: NAME AND ADDRESS OF INSURED OR EMPLOYER LOCATION OF PROPERTY, DESCRIPTION OF OPERATIONS, BUSINESS CONDUCTED ERNEST Be HEFLEY, MELVIN A. HEFLEY & STANLEY L. HEFLEY, DBA: MIDWAY EQUIPMENT RENTALS 14141 HUNTINGTON BEACH BOULEVARD WESTMINSTER2 CALIFORNIA KIND OF INSURANCE POLICY NUMBER EXPIRATION LIMITS OF LIABILITY BURGLARY $ $ r GLASS Replacement BODILY INJURY LIABILITY Other Than Automobile* 100 thousand dollars, each person 20 6 300 thousand dollars, each accident CGL 25 49 16 11 / / 5 300 thousand dollars, aggregate products PROPERTY DAMAGE Liability other than Automobile* 25 thousand dollars, each accident 25 thousand dollars, aggregate operations it It 25 thousand dollars, aggregate protective 25 thousand dollars, aggregate products 2 thousand dollars, aggregate contractual AUTOMOBILE: Bodily Injury Liability* tt tt 100 thousand dollars, each person 00 thousand dollars, each accident Property Damage Liability* 25 thousand dollars, each accident Medical Payments $ each person Comprehensive—Loss of or Damage to the Actual Cash Value Unless Otherwise State Herein Automobile, Except by Collision or Upset but including Fire, Theft and Windstorm $ Collision or Upset Actual Cash Value less $ deductible Actual Cash Value Unless Otherwise Stated Herein Fire, Lightning and Transportation Theft (Broad Form) Year Trade Name Body Type Serial or Motor Number Schedule Additional Automobiles on ALL OWN ' t NON—OWNED AND HIRED AUTOMOBILES. Reverse Side. ALL OP PIONS OF THE INSUR ED INCLUDING COMPLETED OPERATIO RS OR PRODUCTS. Special Conditions or Coverages TEN DAYS NOTICE WILL BE GIVEN IN EVENT OF CANCELLATION. JACK C. YOUNG INSURANCE P. 0. Box 188, 14241 E. Imperial Hwy. UNiversity .• LA . • •If Comprehensive, so state. If not Comprehensive, for "other than Auto," list form such as OLT, ELEV., etc. In event of any material change in or cancellation of the policy or policies, the Company JACK C. YOUNG INSURANCE AGENCY will make every effort to notify the addressee but undertakes no responsibility by reason By a� of failure to do so. CRT I (ED.2-62) 28M 2.62 Authorized Representative ►A..l....._ �_ AJ. TEFL t y NOTICE OF CANCELLATION OF INSURANCE POLICY POLBBB INS1102 lrE �'gjwp � gr {y H( OFFICE—818 W. ith STREET, LOS ANGELES 17, FORNIA POLICY No. �+ ��g3-�7 TO ALL INSURED(S), MORTGAGEES, AND LOSS PAYEES NAMED IN THE POLICY DESCRIBED BELOW: TAKE NOTICE THAT THE SAID POLICY IN ITS ENTIRETY, INCLUDING ANY MORTGAGEE OR LOSS PAYABLE CLAUSE,IS HEREBY CANCELLED AS TO ALL INTERESTS INSURED. THE EFFECTIVE DATE OF CANCELLATION SHALL BE AS SHOWN BELOW. PREMIUM ADJUSTMENT: If premium for said policy has not been paid, the earned premium due and payable shall be computed as provided in the policy, and demand is hereby made for payment thereof. If premium has been paid, the excess paid premium, if any, above the earned premium, if not tendered with this cancellation notice, will be refunded as soon as practicable after cancellation be- comes effective. Named � REASON FOR CANCELLATION Insured Ernest B. Hefley, m'elvin Ai Hefley =ON-PAYMENT ❑ INSUREDS REQUEST Stanley L. Roj ley D t ❑ COMPANY ELECTION ❑ OTHER Midxay Equipment Rentals 14141 Huntington Beach Blvd BRLB®B ®NSUBBNCE C®MPRNr L_ Westminster, California By Falter Rover AGENT'S CODE NO EFFECTIVE DATE OF CANCELLATION 7/65 19 l l�/jy Date Mailed at the hour of 12. Sta dard Time I.oS Angeles, California F Mailed From Policy Issued �f through J$( Box Young Ins.Agency P.C. (Agent) C �i• ox 188 La Mirada3 California L _J (- -1 Clerk i Mortgagee City Or Loss Payable City of fluntington Beach '---> Huntington Bea.da, Calif ornia L I X5 MORTGAGEE'S COPY