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Insurance - Municipal Underground Services - Workers Comp 2017-11-05CERTHOLDER COPY P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 11-05-2017 COSTA MESA SANITARY DISTRICT 628 W 19TH ST COSTA MESA CA 92627-2716 GROUP: POLICY NUMBER: 1714355-2017 CERTIFICATE ID: 65 CERTIFICATE EXPIRES: 11-05-2018 11-05-2017/11-05-2018 SP 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 fpolicy described ,herein is subject to all the terms, exclusions, and conditions, of such policy. Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2016-11-05 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: COSTA MESA SANITARY DISTRICT ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 11-05-2003 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. RECEIVER OCT 3 0 2017 EMPLOYER Costa Ives" S'nitary oistrict MUNICIPAL UNDERGROUND SERVICES, INC. SP -0? 28511 BRECKENRIDGE DR LAGUNA NIGUEL CA 92677 --2 LAGUNA M0408 (REV.] -2014) PRINTED : 10-17-2017 SP