2012/03/16 Adame Landscape, Inc. Self-Insurance for Workers' Compensation CoverageEBS1
A Hum Resource Mmwganent Company
March 16, 2012
ADAME LANDSAPE, INC
41863 JUNIPER STREET
SAN DIEGO, CA 92562
Re: Barrett Business Services, Inc. ("BBSI")
Letter of Self -Insurance for Workers' Compensation Coverage
For ADAME LANDSAPE, INC, CSLB license number 643164
City of Menifee
MAR 23 i
Received
As the named addressee of this Letter, your company's required workers' compensation coverage is provided through
BBSI's state approved Self -Insured Workers' Compensation Plan. As a party to a co -employment contract with BBSI,
which is effective from 4/1/2012 to 3/31/2013, California Labor Code §3602 allows ADAME LANDSAPE, INC to obtain its
workers' compensation coverage from BBSI.
BBSI's California customers can also verify BBSI's state certification at www.dir.ca.gov./SIP/sip.html; next, click on "Self
Insured Employers"; then "Rosters"; then scroll down to Barrett (the list is alphabetical by company name). Additional
information is as follows:
Self -Insurance Certification Number:
California:
2246
O reg on:
1068
Washington:
706, 116
Delaware:
152
Maryland:
11365
Colorado:
463
Notice of Termination: In the event the contract between BBSI and ADAME LANDSAPE, INC is terminated, BBSI must
provide notice of the termination within seven (7) days to the California Contractors State License Board ("CSLB").
Other Comments (place an "X" if applicable):
FX Named "Letter Holder": City of Menifee 29714 Haun Road Menifee, CA 92586
(EE Other: City of Menifee Sun City Right of way Landscaping Project. Additional Letter Holder: The City of Manifee, its
officers, employees, representatives, attorneys, and volunteers. 30 Day Notice of Cancellation notification
will be provided when possible.
Additionally, BBSI's self -insured program is further supported by an excess workers' compensation insurance policy with
National Union Fire Insurance Company of Pittsburgh, PA. Copy of certificate is available upon request.
For additional information, please contact your local BBSI office at: (858) 314-1100
Very truly yours,
=�*11/
Michael L. Elich
President and Chief Executive Officer
BBSI Office: SAN DIEGO
doc: LOSI-3
8100 NE Parkway Drive, Suite 200 Vancouver, Washington 98662 800.494.5669 360.828.0700 Fax 360.828.0701 www.barrefibusiness.com
PARTNERS IN PROFITABILITY