2012/06/29 Adame Landscape, Inc. Self-Insurance for Workers' Compensation CoverageEBS1
A Human Resource Management Company
June 29, 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
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
Oregon:
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):
XD Waiver of Subrogation: BBSI and ADAME LANDSAPE, INC agree to waive their right of subrogation for the
benefit of:
City of Menifee at
FX Named "Letter Holder": City of Menifee 29714 Haun Rd Sun City, CA 92586
® Other: RE: All Operations
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,
C�
Michael L. Elich BBSI Office: SAN DIEGO
President and Chief Executive Officer doc: Losl-3
8100 HE Parkway Drive, Suite 200 Vancouver, Washington 98662 800.494.5669 360.828.0700 fox 360.828.0701 www.barrefthusiness.com
PARTNERS IN PRCIFITABILITY