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P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 01-01-2010 GROUP: 000713 <br />POLICY NUMBER: 0023353-2009 <br />CERTIFICATE ID: 36 <br />CERTIFICATE EXPIRES: 01-01-2011 <br />01-01-2010/01-01-2011 <br />NB JOB:ALL CALIFORNIA OPERATIONS <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 />tTHORIZED REPRESENTATI PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #1600 - BALCH, THOMAS, TREASURER - EXCLUDED. <br />ENDORSEMENT #1600 - BALCH JR, WILBUR, PRESIDENT - EXCLUDED. <br />ENDORSEMENT #1600 - BALCH, LAFONDA, SECRETARY - EXCLUDED. <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 01-01-2008 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />BALCH PETROLEUM CONTRACTORS & BUILDERS INC <br />PO BOX 361230 <br />MILPITAS CA 95036 <br />0410 <br />IREv.2-051 PRINTED : 12-17-2009 <br />M <br />