Insurance - Atlas Underground - 1995-08-01 • - ..'eer-.^ 'f?5:;•t r-trr.r.«, f'.r,_t:'L"' -: ..I"I,,.. 4.-1:, ...... „ r. -` 4. .
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INSURANCE S- '�T`
FUND CERTIFICATE OF WORKERS' COMPENSATION.'•INSURANCE- `''
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ISSUE DATE 08-01-95 :?'.'Sf, CERTIFICATE.EXPIRE S: :Oa-01-88''?_`%.19.piii y'!;;:i;
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COSTA MESA SANITARY DISTRICT -,.,,E-41.7c t. + .. .
77 FAIR DRIVE y,. :k1 i, IL • :- - J09 <EMP c•.ia':,
COSTA MESA CA 92628 :...t<<x, `{,�''..:>^;;° y9�n2 ` c
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This is to certify that we have issued-a'velid�`Workers�'Compensation;msuranceopohcy:-in��a�form^approvetl":bg<the '•California Insurance Commissioner to the employer named-,below yf�or:'the>>.policy;period.mdicatod.
This policy is not subject to cancellation by„the Fund'except,u'pon'3 days.aedv`ance-"written otice;to 'the employer
We will also give you 30 days advance noticOisliould'this-policy bepcancelledtipiior'to^.itsmormal'.expiration: . 't
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This certificate of insurance is not an insurance policy,"and does:not�,amend;'extend��or"alter the coverage afforded
by the policies 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 may pertain,_the insurance afforded by the
policies described herein is subject to all the terms, exclusions•and•.conditions ofd such Policies. , '<•s.
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EMPLOYER S LIABILITY LIMIT INCLUDING- DEFENSE COSTS•;";41 000 0000000 PER OCCURRENCE
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STANDARD EXCLUSION: INDIVIDUAL EMPLOYERS AND-HUSBAND,ANDt•WIFE;?EMPLOYERS':AREINOT 'ELIGIBLE'
FOR BENEFITS AS EMPLOYEES UNDER THIS POLICY 's' ^
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS, NOTICE EFFECTIVE, 08/01'/95 IS.ATTACHED TO AND
FORMS A PART OF THIS POLICY Al.".
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�' ,LEGAL NAME- ;'a?"s s tssc'
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ATLAS UNDERGROUND CO' , -„.' .04,- n„M ty . .;,,LOYA;}HECTOR AND gr. N
P 0 BOX 951 ;, '4-- '1^y ' r ta1'b -a L'01'A CHRISTY -?.ta
CHINO CA 91708 ar c;Pfi"e :s.£'c`' .-.C.:`,r; .i' •Lai:,.i-
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THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND - 5CIF.10265(REV.2951
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