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■� 21 2017 03:16PM R&M Dulling 12097722767 page 1 <br /> ■ <br /> i■ LrRTHOLDER COPY <br /> NF <br /> STATE P.O. BOX 8192, PLEASANTON, CA 945BB <br /> FUND <br /> CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> ISSUE DATE: 07-24-2017 GROUP: <br /> POLICY NUMBER: 9149165-2016 <br /> CERTIFICATE ID: 1 <br /> CERTIFICATE EXPIRES: 12-25-2017 <br /> 12-25-2018/12-25-2017 <br /> CONTRACTORS STATE LICENSE BOARD NF LIC PERMIT#: 1017078 <br /> WORKERS COMPENSATION UNIT INCEPTION DATE-12-25-2018 <br /> PO BOX 2B000 DII <br /> SACRAMENTO CA 95826-0026 <br /> This is to certify that we have issued a valid Workers' Compensation insurance policy n a form approved by the <br /> California Insurance Commissioner to the employer named below for the policy period irdicated. <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 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 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 /> .�C.7 <br /> Authorized Representative President and CEO <br /> EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br /> ENDORSEMENT #1800 - ROBERT VICKERY PRESIDENT - EXCLUDED. <br /> ENDORSEMENT #1600 - TIFFANY MCGEE SEC,TRES - EXCLUDED. <br /> EMPLOYER <br /> R & M WATER WELL DRILLING & PUMPS INC NF <br /> 6000 SOUTHWORTH RD <br /> VALLEY SPRINGS CA 95252 <br /> [DMO,CN� <br /> (REV 7-9nlal PRINTED 07-24-2017 <br /> Received Time Sep, 21, 2017 4: 14PM No- 2342 <br />