2014/01/10 Adame Landscape, Inc. Self-Insurance for Workers' Compensation CoverageB�Ong
A Hmnan Resource Management Company
January 10, 2014
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
832519
City Of Pvlen tecz
JAN 13 2014
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 4/1/2013 until 4/1/2014, 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 http://www.dir.ca-gov/osip/PrivateRoster.pdf; then
scroll down to Barrett (the list is alphabetical by company name). Additional information is as follows:
State: California Employer Liability Limits:
Self Insurance Certification #: 2246 $5,000,000.00 Each Accident
$5,000,000.00 Disease Coverage Limit by Client
---------------- -----
$5,000,000.00 Disease; Each Employee
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):
Waiver of Subrogation: BBSI and ADAME LANDSAPE, INC agree to waive their right of subrogation for the
benefit of:
City of Menifee at
XO Named "Letter Holder': City of Menifee 29714 Haun Rd Sun City, CA 92586
® Other. Project Name: Cherry Hills Blvd. Street Median. 30 day notice of cancellation will be provided when possible
Additionally, BBSI's self -insured program is further supported by an excess workers' compensation insurance policy with
ACE American Insurance Co. Copy of certificate is available upon request.
For additional Information, please contact your local BBSI office at:
Very truly youAV;L2rs,
Michael L, Elich
President and Chief Executive Officer
SAN DIEGO
(858) 314-1100
10935 Vista Sorrento Parkway Suite 150
San Diego, CA 92130
doc: L051-3