Insurance - Kennedy - 2002-01-28 SC
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STATE P.O. BOX 807 SAN FRANCISCO,CA 94101-0807
COMPENSATION JAN-2 8" 002
INSURANCE
FUND I ® CERTIFICATE OF WORKERS' COMPENSATION INSURANCE COSTA ESA SARRARY MIRJ[
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POLICY NUMBER: 6653001 02
ISSUE DATE: 02-02-02 CERTIFICATE EXPIRES: 02-02-03
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COSTA MESA SANITARY_DISTRICT JOB EMERGENCY- SERVICES
N ATTN JOAN' REVAK w- : f,. . v
P 0 BOX '1200 c_;
COSTA ''MESA 'CA 92628-1200 . ,., ,.
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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. _
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This policy is not subject to cancellation by the Fund except upon 30days' advance written notice-to the emolover t
We will also give you 30 days;,advance notice should this policy be cancelled prior to its normal-expiration. ', `
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This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage"afforded r -rz
by the policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other docum`ent •y.'
with respect to which this certificate of insurance 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. >. .
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PRESIDENT
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EMPLOYER'S LIABILITY LIMIT INCLUDING.DEFENSE COSTS 51. 000 000 00 PER OCCURRENCE +'
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS NOTICE EFFECTIVE 02/02/02 IS ATTACHED.TO'AND z
FORMS A PART OF THIS,POLICY' "
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*.EMPLOYER- :;,' ='4 LEGAL,NAME 9 A
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KENNEDY PIPELINE COMPANY A,CORP KENNEDY PIPELINE.COMPANYz(A:CORPyt -.w.
61 ARGONAUT .Jt .k CHANNEL EQUIPMENT'.CO' - _ "
ALISO VIEJO CA 92856 z- '�` - 'Ft,
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rev, i-ifizttm , ,r ,LatZr F",a i 40/THIS,DOCUMENT HASA BLUE;PATTER NED BACKGROUND '.r,¢^".i°, ±, .1 sclF 19265(REV.2 pi) .tr