2021/08/12 Nancy K. Bohl, Inc.CERTHOLDER COPY
SP
P.O. BOX 8192, PLEASANTON, CA 94588
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 08-12-2021
CITY OF MENIFEE SP
29844 HAUN RD
MENIFEE CA 92586-6539
GROUP:
POLICY NUMBER: 0702761-2021
CERTIFICATE ID: 115
CERTIFICATE EXPIRES: 08-12-2022
08-12-2021/08-12-2022
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 wher 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
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2020-08-12 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED:
CITY OF MENIFEE
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 08-12-2011 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2021-08-12 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME:
CITY OF MENIFEE
ENDORSEMENT #1651 - NANCY K BOHL, P,S,T - EXCLUDED.
EMPLOYER
NANCY K BOHL INC SP
1881 BUS CTR DR STE 11
SAN BERNADINO CA 92408
M0408
(REV.7-2014) PRINTED : 07-15-2021