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21 2017 03:16PM R&M Dulling 12097722767 page 1 <br />■ <br />0■ c:rRTHOLDER COPY <br />STATE1.D �11P�N P.O. BOX 8192, PLEASANTON, CA 94588 <br />FUND <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 07-24-2017 <br />CONTRACTORS STATE LICENSE BOARD NF <br />WORKERS COMPENSATION UNIT <br />PO BOX 26000 <br />SACRAMENTO CA 95826-0026 <br />GROUP: <br />POLICY NUMBER: 9149165-2016 <br />CERTIFICATE 16: 1 <br />CERTIFICATE EXPIRES: 12-25-2017 <br />12-25-2016/12-25-2017 <br />LIC PERMIT#: 1017078 <br />INCEPTION DATE:12-25-2018 <br />DO:NF <br />This is to certify that we have issued a valid Workers' Compensat'on insurance policy n 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 10 days advance written notice to the employer. <br />We will also give you 10days 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 al: the terms, exclusions, and conditions, of such policy. <br />Authorized Representative President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #1600 - ROBERT VICKERY PRESIDENT - EXCLUDED. <br />ENDORSEMENT #1600 - TIFFANY MCGEE SEC,TRES - EXCLUDED. <br />n <br />EMPLOYER <br />R & M WATER WELL DRILLING & PUMPS INC NF <br />8000 SOtJTHWORTH RD <br />VALLEY SPRINGS CA 55252 <br />[DMO,CN[ <br />(REV 7-9rl PRINTED : 07-24-2017 <br />Received Time Sep. 21, 2017 4:14PM No, 2342 <br />NF <br />