2019/02/01 Barrett Business Services, Inc. Certificate of Liability Insurance,tee R� CERTIFICATE OF LIABILITY INSURANCE
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DATE (MM/DD/YYYY)
1 /30/2019
'THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE
.AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE
ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGRATION IS WAIVED,
subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does
not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER Willis Towers Watson
CONTACT NAME: San Dieqo
12980 Metcalf Ave Suite 500
PHONE (A/C, No Ext): (858) 314-1100 FAX (A/C, NO): (360) 828-0699
Overland Park KS 66213
EMAIL ADDRESS: EIke.Wohlgemuthp_bbsihq.com
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A: ACE American Insurance Company 22667
INSURER B:
INSURED
;Barrett Business Services, Inc. L/C/F
HEARTLAND GRADING
INSURER C:
:3142 TIGER RUN COURT STE 114
INSURER D:
OARLSBAD, CA 92010
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
'THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.
(NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE
,ISSUES OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF
:SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IINSR
TYPE OF INSURANCE
ADDL
SUBR
POLICY NUMBER
POLICY EFF
POLICY EXP
LIMITS
ILTR
INSR
WVD
(MMIDDIYYYY)
(MM/DD/YYYY)
GENERAL LIABILITY
EACH OCCURRENCE
$
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE DOCCUR
CI
, of Menif
city Clerk
ee
DAMAGE TO RENTED PREMISES (Ea
-occurence)
$
MED EXP (Any one person)
$
PERSONAL & ADV INJURY
$
F
3 ® 4 20
IJ
JIn
GENERAL AGGREGATE
$
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG
$
POLICY PROJ- LOC
$
ECT
AUTOMOBILE LIABILITY
ANY AUTO
Received
COMBINED SINGLE LIMIT
(Ea accident)
$
BODILY INJURY (Per person)
$
ALL OWNED AUTOS SCHEDULED AUTOS
BODILY INJURY (Per accident)
$
HIRED AUTOS NON -OWNED AUTOS
PROPERTY DAMAGE
$
UMBRELLA LIAB OCCUR
EACH OCCURRENCE
$
i EXCESS LIAB OCCUR
AGGREGATE
$
i DED RETENTION $
$
A
WORKERS COMPENSATION AND EMPLOYERS'
C66008708
02/01/19
02/01/2020
�/
WC STATU-
OTH-
LIABILITY Y/N
TORY LIMITS
ER
E.L. EACH ACCIDENT
$2,000,000
ANY PROPRIETOR/PARTNER/ EXECUTIVE Y
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) If yes, describe under
DESCRIPTION OF OPERATIONS below
N / A
X
Covered states:
CA
E.L. DISEASE - EA EMPLOYEE
$2,000,000
E,L. DISEASE - POLICY LIMIT
$2.000.000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
In the event of any payment under this policy for a Loss for which the named insured has waived the right of recovery in a written contract entered into prior to
the Loss, insurer hereby agrees to also waive our right of recovery but only with respect to such Loss.
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
CITY OF MENIFEE
EXPIRATION DATA THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
POLICY PROVISIONS.
29714 Haun Road
AUTHORIZED REPRESENTATIVE
Menifee Ca 92586
Authorized
Rep
c) 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD.
AGENCY CUSTOMER ID.
LOC: 'I;
P1VV1 I IVINP1L 1\LIrIP11\f\V VV1 1LvvL1- rage Z oT Z
AGENCY NAMEDINSURED:
Barrett Business Services, Inc. L/C/F
Lockton Affinity HEARTLAND GRADING
POLICY NUMBER 3142 TIGER RUN COURT STE 114
CARLSBAD, CA 92010
C66008708
CARRIER NAIC CODE
ACE American Insurance Company 22667 EFFECTIVE DATE: 02/01/19
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Certificate of Liability (01/14)
CERTIFICATE HOLDER: CITY OF MENIFEE
ADDRESS: 29714 Haun Road Menifee Ca 92586
RE: All Operations. 30 day notice of cancellation will be provided when possible.
ACORD 101 (2008/01) c) 1988-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD.
Workers' Compensation and Employers' Liability Policy
Named Insured
Endorsement Number
Barrett Business Services, Inc.
Policy Number
L/C/F HEARTLAND GRADING
8100 NE Parkway Drive, Ste. 200
Symbol: Number: C66008708
Vancouver, WA 98662
Policy Period
Effective Date of Endorsement
2/1/2019 TO 2/1/2020
2/1/2019
Issued By (Name of the Insurance Company)
Ace American Insurance Co.
Insert the pollcy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy.
CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
This endorsement applies only to the insurance provided by the policy because California is shown in Item
3.A. of the Information Page.
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will
not enforce our right against the person or organization named in the Schedule, but this waiver applies
only with respect to bodily injury arising out of the operations described in the Schedule, where you are
required by a written contract to obtain this waiver from us.
You must maintain payroll records accurately segregating the remuneration of your employees while
engaged in the work described in the Schedule.
Schedule
1. ( ) Specific Waiver
Name of person or organization.
(x) Blanket Waiver
Any person or organization for whom the Named Insured has agreed by written contract to furnish this
waiver.
2. Operations:
3. Premium:
The premium charge for this endorsement shall be INCLUDED percent of the California premium developed
on payroll in connection with work performed for the above person(s) or organization(s) arising out of the
operations described.
4. Minimum Premium: INCLUDED
Authorized Agent
WC 99 03 22