2013/06/14 Richard Lee Sherman's Plumbing Page 3
WORKERS' COMPENSATION INSURANCE
This contractor:
❑ has no employees and is exempt from workers' compensation requirements.
® carries workers' compensation insurance for all employees.
A copy of the contractor supplied certificate of workers' compensation insurance coverage is
attached to this Contract.
COMMERCIAL GENERAL LIABILITY INSURANCE
This contractor:
❑ does not carry commercial general liability insurance
❑ carries commercial general liability insurance written by:
You may call the insurance company at
AT Walters Insurance Company
Phone - (909) 383-5023
to check the contractor's insurance coverage.
A copy of the contractor supplied certificate of general liability insurance coverage is attached
to this Contract.
007
Dec 10 00 09:13p Shermans Plumbing 9512428220 p.1
h e J POLICYHOLDER COPY
NA
• P.O, BOX 8192, PLEASANTON, CA 94568
■
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 12-05-2013 GROUP;
POLICY NUMBER: BOBE736-2013
CERTIFICATE ID: 1
CERTIFICATE EXPIRES: 07-27-2014
07-27-2019/07-27-2Ot4
CITY OF MENIFEE NA
29714 HAUN RD
SUN CITY CA 92580-6540
This Is to certify that we have issued a valid Workers' Compensetian 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 10 days advance written notice to the employer.
We will also give you 10 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 conditlaos, 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 Ol A HUSBAND AND WIFE EMPLOYER;
EMPLOYEES COVERED ON A COMPREHENSIVE PERSONALLIABILITY INSURANCE POLICY ALSO AFFORDING
CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS'
COMPENSATION LAW,
_— EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: 51,000,000 PER OCCURRENCE.
I
I
i EMPLOYER
SHERMAN, RICHARD AND SHERMAN, ROCHELLE NA
30623 aDEOIAH SMITH R0
TEMECULA CA 92S92
[JAT,CS)
IREV.1-20121 PRINTED 12-05-2013
00t 08 13 02148p n T WFILTERS INS 9093835030 p. 1
OAT I DD YVVV)
ACORr_) CERTIFICATE OF LIABI_LI INSURANCE 1EO��Bf13
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 AFFOR081a BY THE POLICIES
BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INBURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,
IMPORTANT: If the cartificgte h01dor 10 an ADDITIONAL INSURED, the pollsyttes)mast he endorsed. If SUBROGATION IS WAIVED,yubjnt to
the terms and conditions of the pollcy,oenaln policies may require an ond(,manir Ent A statement on this certlficato does not cantor rights to the
rnODOCBRste hador in lieu of suph endorsements, NeME B,�y yBARR
242 L AIRPORT DADRIVEP,' B"J' BTT
A T WALTERS INSURANCE AGENCY 6`NAIL E3 5025—.... ..—I,C'8. „1...._._ ........ ....
alc u
SUITE 105 IN9URERlSI gFFOR01rya COVtlRAGQ,,,—_,_„ N,_,,,,,
SAN BERNARDINO CR 92106 IN 6TRA A;COL01iY_TNOVa"CE
INSURED msufteRe1,—_" .._.�.... .... . �,... ....-_. ...._.
RICHARD LEE SHERNAN'S PLUMBING �NguRERc: "
30623 aDEDIAH SMITH RU•
INSURaRE:
TEMECULA CA 92592 IN SURER EI
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS T'D CERTIFY THAT THE POLICIES OF INSURANCE LIS'fE0 BELOW HAVE BEEN I55UE0 TU THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION 011 ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
•0 ALL THE TL%iMS,
INa eNEHALLITYE OF NaUTION90''SUCH POL DIES. GL9056766MAYpIAV[;DI:LN ROe/4/30lii 001/lA/P 01P OAM 1 ,To
�'IM-
CERT'IFICA E ISSUEU OR MAY PERTAIN THE INSURANCE AFFORDEC BY THE POLICILS OESCRIBU
AND
LTR EXCLUSIONS RCIA GG URANC6 POLICY NUMeaR M 1 o MIDD Y HT
_y —' A UL SU§R—" PGLI POLIC E P
CLAIMS MADE A Mh EACH OCCURRENCE
O'Ereo01 F — LD50aD
NB
30,000
COh "N6RAL LIAtlILITY ,j"—AMT(TCA ICE e{Oy;J} t—_
OCCUR PBRSUNAL a ADV INJURY t 1.00000..00
00
A '
_ — CEd RAL aaG,I,P anT�, 3 20 0000
13 LAOOREGATCLIMn AFHLIESPCM 4A000CTS,COMWOFAGG S —
_ 2000000
POLICY 'I R O LOC 0
RV*DmOe LIADIUTY 'INFO 61N4LE LIMIT
aE
OOOILY M...__...JORY`Fe..rpWOCn) 0`— il•
ANY AUTO __..... . .. . _5. .._
�• ALL OLANEO '1 SCHEOULF.O 9001LY INJVRV Pel'ecol0onl) $
... AVYOS AUTOS 'pROPEFfV DnRnnc�"".
$
HIHLU hu IUS _ AV ubNavFC
UManELU LIAR _ OCCUR EACHOCCURRENCE _ S •-
E%CEdS LIAP CLAIM6 MAac AGGREGATE 5
01,0 RETENTIONS
WORKERS COMPONAAT10N Vv(:STATW GTH
! AND EMPLOYfRVLIARIUYY YIN
ANYPIOP(IIETOHIFARTNCWE.%E.LII'Nn NIA CAL.EAGr1 ADC0MT Y
OFFICERIMCNIBERENLUDED1 _ '
(Afend@IOIY In Nil) EI,.DIR E. .-. EA�MPLOYE i _- „•„
It r,•�n tlP80ib0 U�dCr E.L.GIBEASE•POLICY LIMIT L
OgIM06zI@I ,, OPERATIONS U@I0w
DESCRIPTION CP OPERATION61 LOCATIONS I VEHICLES(AOBa11 ACOPO 10t,AOOWonal Rom01k@ SaHadula,If Illol4•p��a Ic roGVllvul
Certificate 1lolder is named as additional insured as respects Operations of the
named insured.
i
CERTIFICATE HOLDER CANCELLATION
City Of Menifee SHOULO ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORC
Attn: M8Tg8Yi to C'oPen o THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANOB WITH THE PVLIOY PROVISIONt.
29714 HE= Rd.
AUTHOMWOREPRFSNNTATIVE
Menifee Ca 92506 \
I
- ti 010@8-2010 ACO COR RATlO A is reS2rved.
ACORO 25(2010105) The AOORO name and logo arm ro&tered marks Or ACORO