HomeMy WebLinkAbout2201 taft hwy_ust removal _5-6POLICYHOLDER COPY NA
STATE
COMPENSATION P.O. BOX 81921, PLEASAWON, CA 94588
INSURANC5
FUND
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 12-13-2019 GROUP:
POLICY NUMBER: 9081.5792019
CERTIFICATE ID: 2
CERTIFICATE EXPIRES: 12-13-2020
12-113-20119112-113-2020
CONTRACTORS STATE LICENSE BOARD NA LIC PERMIT#: 708267
WORKERS COMPENSATION UNIT INCEPTION DATE:12-13-2019
PO BOX 26000 DO:NA
SACRAMENTO CA S5826-0026
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 10 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, ex-tend or alter 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.
let
Authorized Representative President and CEO
UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWIW:
THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL E14PLOYER OR A 14USBAND AND WIFE EMPLOYER;
EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING
CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS'
C014PENSATION LAW -
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EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
EMPLOYER
SIMON, DAVID DBA: SHANCOR NA
14052 LARCH LN
TUSTIN CA 92780
PRINTED : 11-18-2019
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