Insurance - Orange Coast Electric - Workers Comp - 2017-12-01CERTHOLDER COPY
PO. BOX 8192, PLEASANTON, CA 94588
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 12-01-2017
COSTA MESA SANITARY DISTRICT
290 PAULARINO AVE
COSTA MESA CA 92626-3314
SP
GROUP
POLICY NUMBER: 9031048-2017
CERTIFICATE ID: 29
CERTIFICATE EXPIRES: 12-01-2018
12-01-2017/12-01-2018
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 30 days advance written notice to the employer.
We will also give you 30 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 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
Jjpolicy
dedescribed
J herein is subject to all the terms, exclusions, and conditions, of such policy.
Authorized Representative President and CEO
UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING:
THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER;
EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING
CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS'
COMPENSATION LAW.
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
ENDORSEMENT X2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 12-01-2012 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
EMPLOYER
IRVINE, JAMES ALAN DBA: ORANGE COAST ELECTRIC
24062 SALERO LN
MISSION VIEJO CA 92691
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(REV.7-2014)
NOV 22 2017
Costa Mesa Sanitary District
PRINTED : 11-16-2017
M0408
SP