HomeMy WebLinkAboutMinor Mod_ Workers Comp info 1.10.19POLICYHOLDER COPY
P.O. BOAC 8192, PLEASANTON, CA 94588
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE.
ISSUE DATE: 02 -22 -2017 GROUP:
POLICY NUMBER: 9090125 -2017
CERTIFICATE ID: 2
CERTIFICATE EXPIRES: 02- 22-'2018
02- 22- 2017/02 -22 -2018
CONTRACTORS STATE LICENSE BOARD SC LTC PERMIT #: 968501
WORKERS COMPENSATION UNIT INCEPTION DATE :02 -22 -2017
PO BOX 26000 DO-.9C
SACRAMENTO CA SS826 -0026
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 t0 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 after the coverage afforded
by the policy 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 to which it may pertain, the insurance
afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy.
r
Authorized Representative President and CEO
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
EMPLOYER
Y & R CONSTRUCTION SERVICE, INC.
11028 HOWARD ST
WHITTIER ,,GA 9
(REV.7 -2014) PRINTED : 01 -17 -2017
SC