2021/01/01 Vanderhule, Daniel B Certificate of Workers' Compensation InsuranceCERTHOLDER COPY
SP
P.O. BOX 8192, PLEASANTON, CA 94588
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 01-01-2021
CITY OF MENIFEE SP
29714 HAUN RD
MENIFEE CA 92586-6540
GROUP:
POLICY NUMBER: 9149583-2021
CERTIFICATE ID: 72
CERTIFICATE EXPIRES: 01-01-2022
01-01-2021/01-01-2022
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 indicated.
This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer
We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration.
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 th/ef 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 01-01-2016 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
EMPLOYER
VANDERHULE, DANIEL B DBA: ROOFTEK ROOFING &
WATERPROOFING
23991 VISTA WAY
MENIFEE CA 92587
M0408
IREv.7-20141 PRINTED : 12-17-2020