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POLICYHOLDER COPY <br />P.O. BOX 8192, PLEASANTON, CA 94588 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 01-01-2018 <br />CONTRACTORS STATE LICENSING BOARD NF <br />STATE OF CALIFORNIA, ATTN: WORKERS COMP UNIT <br />P 0 BOX 26000 <br />SACRAMENTO CA 95826 <br />GROUP: <br />POLICY NUMBER: 9121068-2018 <br />CERTIFICATE ID: 2 <br />CERTIFICATE EXPIRES: 01-01-2019 <br />01-01-2018/01-01-2019 <br />LICENSE NUMBER:LICENSE N 468732 <br />INCEPTION DATE:01-01-2018 <br />DO:NF <br />This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the <br />California Insurance Commissioner to the employer named below for the policy period indicated. <br />This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. <br />We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. <br />This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded <br />by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document <br />with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance <br />afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. <br />Authorized Representative President and CEO <br />UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING: <br />THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER; <br />EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING <br />CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS' <br />COMPENSATION LAW. <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT 112065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 01-01-2015 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />SILVEIRA, JOE B. AND SILVEIRA, PAULETTE A. <br />260 AIRPARK RD <br />ATWATER CA 95301 <br />PRINTED : 12-15-2017 <br />(REV.7-2014) <br />NF <br />M0409 <br />