Insurance - Kennedy - 2003-01-27 CERTHOLDER COPY
STATE P.O. BOX 807 SAN FRANCISCO,CA 94,142-0807 RECEIVED
COMPENSATION
INSURANCE JAN.2 7 2003
FUND CERTIFICATE OF WORKERS' 'COMPENSATION INSURANCE L II LO
&WA MESA SWAM'Orr
ISSUE DATE: 02-02 2003 GROUP-
POLICY NUMBER: 6653001 2003
CERTIFICATE ID; 101
CERTIFICATE EXPIRES: 02-02-2004
1 02-02-2003/02-02-2004
"COSTA MESA SANITARY DISTRICT SK JOB EMERGENCY SERVICES
ATtN. J0AMMI•RtEVAK
P 0 BOX 1.200
COSTA MESA; CA 92628-1200
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,g0,deys advance notice should this policy be cancelled prior to-its normal expiration.
This dertifieate..of insurance is net an insurance policy and does not amend, extend or alter the doyerage afforded
by the policies listed herein. "No{vvithstandin9 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 of such policies.
m -
AUTHORIZED REPRESENTATIVE PRESIDENT
-EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS. Si' 000;000 00 PER OCCURRENCE
4
ENDORSEMENT #2066;ENTITLED CERT,IF„ICATE HOLDERS NOTICE-EFFECTIVE• 02-02-2003 IS ATTACHED-4TO AND
'a-FORMS ,A PART OF THIS 'POLICY
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EMPLOYER
-LEGAL NAME
KENNEDY P1 PEt I N? COMPANY A CORP KENNEDY PIPELINE COMPANY (A CORP)AND/C
61 ,ARGONAUT CHANNEL EQUIPMENT CO (A CORP)
AL I SO, V•I EJO CA> 92656
-s' 01 16-2003
- PRINTED: P0408
• THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND • sciF 10265(REV.2-01)