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POLICYHOLDER COPY <br />P O BOX 8192. PLEASANTON, CA 94588 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE 11-29 2017 <br />CONTRACTORS STATE LICENSE BOARD <br />WORKERS COMPENSATION UNIT <br />PO BOX 26000 <br />SACRAMENTO CA 95626 0026 <br />GRULIP. <br />POLICY NUMBER, 9053901 2017 <br />CERTIFICATE 117 2 <br />CERTIFICATE EXPIRES 11-26-2018 <br />11-29-2017/11 29-2018 <br />NF LIC PERMITx 954267 <br />INCEPTION DATE.11-29-2017 <br />DO NF <br />This Is Io cxUfy t9at we have issued a valid Workers' Compensation Insurance Policy In a form approved by the <br />Califomia Insurance Commissioner to the employer named below for the policy Period ind,caled <br />This pol,cy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer <br />We will also give you 10 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 feWiremenl, term or condlhon 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 alt the terms, exclusions, and Conditions. of such policy <br />Authorized Represontat ve President and CFC <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 Al SO AFFORDIW, <br />CALIFORNIA WORKERS- COMPENSATION BENEFITS. EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS <br />COMPENSATION LAW <br />EMPLOYER S LIABILITY LIMIT INCLUDING DEFENSE COSTS 51.000.000 PER OCCURRENCE <br />,-Mp. - - - <br />SCOTT THOMAS ANDREW DBA GEO - EX DRILLING <br />1510 MADERA DR <br />DIXON CA 95820 <br />I <br />PRINTED : 10-17-2017 <br />M0409 <br />NF <br />