2018/09/01 Arroyo Background Investigations Certificate of Workers' Compensation InsuranceCERTHOLDER COPY SP
City of Menifee
Finance
P.O. BOX 8192, PLEASANTON, CA 94588
ISSUE DATE: 07-26-2019
CITY OF MENIFEE
29714 HAUN RD
MENIFEE CA 92586-8540
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
SP
GROUP: received
POLICY NUMBER: 1883950-2018
CERTIFICATE ID: 28
CERTIFICATE EXPIRES: 09-01-2019
09-01-2018/09-01-2019
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the
California Insurance Commissioner to the employer named below for the policy period that will expire or did
expire as indicated above.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document
with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance
afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy.
Authorized Representative
President and CEO
UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING:
THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER;
EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING
CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS'
COMPENSATION LAW.
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 09-01-2012 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
EMPLOYER
ARROYO, ERIC JASON AND ARROYO, TERISIA
19510 VAN BUREN F-3-192
RIVERSIDE CA 92508
SP
M0408
(REV.7-2014)
PRINTED : 07-29-2019