2020/09/01 Workers' Compensation Policy 1863950-2020CERTHOLDER COPY
SP
P.O. BOX 8192, PLEASANTON, CA 94588
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 06-02-2021
CITY OF MENIFEE POLICE DEPT
29714 HAUN RD UNIT A
MENIFEE CA 92586-6540
SP
GROUP:
POLICY NUMBER: 1863950-2020
CERTIFICATE ID: 36
CERTIFICATE EXPIRES: 09-01-2021
09-01-2020/09-01-2021
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 the policy described herein is subject to all the terms, exclusions, and conditions, of such policy.
e;�-�ez`
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 (and) Arroyo, Terisia
19510 VAN BUREN F-3-192
RIVERSIDE CA 92508
SP
M0408
(REV.7-2014) PRINTED : 06-03-2021