Insurance - Municipal Underground Services, Inc.Workers' Comp - 2015-11-05CERTHOLDER COPY RECEIVED
OCT 2 6 2015
P.O. BOX 8192, PLEASANTON, CA 94588 COSTA MESA SANIIARY UISTRIC[
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 11-05-2015
COSTA MESA SANITARY DISTRICT
628 W 19TH ST
COSTA MESA CA 92627-2716
GROUP:
POLICY NUMBER: 1714355-2015
CERTIFICATE ID: 65
CERTIFICATE EXPIRES: 11-05-2016
11-05-2015/11-05-2016
SG JOB:COSTA MESA SANITARY DISTRICT
628 W. 19TH STREET
COSTA MESA
CA 92627-2716
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 policy
described ,herein is subject to all the ter./mss,, exclusions, and conditions, of such policy.
db
Authorized Representative President and CEO
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
ENDORSEMENT #1600 - DAVID BOUTELLE, PRIES - EXCLUDED.
ENDORSEMENT #1600 - ANN BOUTELLE, VP SEC TRES - EXCLUDED.
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 11-05-2003 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
EMPLOYER
MUNICIPAL UNDERGROUND SERVICES, INC. SG
28511 BRECKENRIDGE DR
LAGUNA NIGUEL CA 92677
(REV.7-2014)
PRINTED : 10-16-2015
M0408
SG