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Insurance - Orange Coast Electric 2019-12-01ISSUE DATE: 12-01-2019 CERTHOLDER COPY P.O. BOX 8192, PLEASANTON, CA 94588 RECEIVED DEC 06 2019 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE Costa Mesa Sanitary District GROUP: POLICY NUMBER: 9031048-2019 CERTIFICATE ID: 29 CERTIFICATE EXPIRES: 12-01-2020 12-01-2019/12-01-2020 COSTA MESA SANITARY DISTRICT 290 PAULARINO AVE COSTA MESA CA 92626-3314 SP 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 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 AN 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. EMPLOYER IRVINE, JAMES ALAN DBA: ORANGE COAST ELECTRIC 24062 SALERO LN MISSION VIEJO CA 92691 0 ,4kfia M0408 (REV.7-2014) PRINTED : 11-18-2019 SP