Insurance-Workers Comp-Orange Coast Electric-2013-12-01CERTHOLDER COPY
P.O. BOX 8192, PLEASANTON, CA 94588
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 12 -01 -2013
COSTA MESA SANITARY DISTRICT SG
628 W 19TH ST
COSTA MESA CA 92627 -2716
GROUP:
POLICY NUMBER: 9031048 -2013
CERTIFICATE ID: 6
CERTIFICATE EXPIRES: 12-01 -2014
12 -01- 2013/12 -01 -2014
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 80 days advance written notice to the employer.
VVe 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 policy described 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 NV 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 #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 12 -01 -2012 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
RECEIVEV
EMPLOYER DEC 0 4 2013
i uoliii mwik SANIiARV DISTRICT
IRVINE, JAMES ALAN DBA: ORANGE COAST ELECTRIC
24062 SALERO LN
MISSION VIEJO CA 92691
M0408
(REV.1 -2012) PRINTED : 11 -15 -2013
SG