2022/01/01 Habitat for Humanity Inland ValleyodQo*CERTIFICATE OF LIABILITY INSURANCE o rE(lrx/Do,lYYY)
12t24t2021
THIS CEBTIFICATE IS ISSUEO AS A MATTER OF INFORMANON ONLY AND CONFEFS NO RIGHTS UPON THE CEPTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY ON NEGANVELY Ai'ENO, EXTEND OB ALTER THE COVENAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSUFANCE DOES NOT CONSIITUTE A CONTFACT BETWEEN THE ISSUING INSUREF(S), AUTHOFIZEO
REPRESENTATIVE OH PRODUCER, AND THE CENNFICAIE HOLDER.
IMPORTANT: ll lhe certlticsle holder ls an ADDITIONAL INSUREO, the policy(ies) mwi have ADOITIONAL INSURED provlslons or be endor3ed.
It SUBROGAfION lS WAIVED, eublect lo the term3 6nd condlllons of the pollcy, cenrln pollclee may requlre an endo.scment. A 3tatement onlhl! c6rlltlcale does not conrer rlghls to lhe conllbtte holder ln lleu ol such endorlemcnt(e).
PCOOUCEB
Arfiur J. Gallagher & Co.
lnsurance B.okers of Calirornia, lnc. LIC# 0726293
1255 Battery Street #450
San Frencasco CA 941'11
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PHOIIE
INSURE F(S) AFFOBOI'IG COVENAGE
rNsuREF a: NonProfts' Unrted Workors' C ensation Grou
la.ltuiED
Habrtat for Humanity lnland Valley
27475 Ynez Road #390
Temecula. CA 92591
COVERAGES CERTIFICATE NUMBEB: 87292697 REVISION NUUBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEO TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INOICATED NOTWITHSTANDING ANY BEQUIFEMENT, TERM OR CONDITION OF ANY CONTBACT OR OTHER DOCUMENT WTIH BESPECT TO WHICH THIS
CEBTIFICATE MAY BE ISSUEO OR MAY PERTAIN, THE INSURANCE AFFOFDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TEBMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAII\,IS.rNrF' rypEorrNsua rcE .?,f,}irtTi poucy *r1EEn ,ffits$Irtr" ,ffiH$Irfi,i, urrs
COUtlENclAI gENEBAL LIAEIUIY
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50 000 $2.000 000 (EL)
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oEgCFlEIlOal OFOPEaAnOI€ / IOCAnONS r VE|IICLES (ACOFD ro!, Addlfioo.l Rrnr.t. !kh.duL, ory b.lr&h.d I mor. t!.c. t! r.qut.d)
CEBTIFICATE HOLDER CANCELLATION
Caty of Mcnifee
29844 Haun Road
Menifee CA 92586
SHOULD AI{Y OF THE AAOVE OESCAIBED POL'CIES 8E CAI{CELLED gEFOf,E
THE EXPIRATIOTI DATE THEREOF, NOTICE WILL SE OELIVERED I}{
ACCOHDATICE WTH THE POLICY PROVISIOT{S.
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O 1988.2015 ACOFD COBFOFATIOI{. All rlghls relcrvod.
Th€ ACORO nlme 8nd logo are regislored msrk! ol ACOFD
2'ot2 29492
ACOFO 25 (2016/03)
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Arthur J. Gallagher & Co. lnsuranco Brokers of CA., lnc.
595 Market Street
Suite 2100
San Francisco. CA 94105
29492 1 AB 0.458 29492
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CITY OF IMENIFEE
29844 HAUN RD
MENTFEE, CA 92586-6539
We are providing you with a Certifrcate of lnsurance confirming our client's coverage.
Want to get certificates of insurance faster? "Go Green with Gallagher" by receiving digital copies of certificates via
e-mail in the future. Or, do you no longer require a certificate of insurance for our client? Please contact us at
COl.uodateMvEmail@AJG.com and orovide the followino information for orocessino:
1 . Confirmation that a certificate of insurance is no longer required; or2. E-mail address to send future certificates of insurance in lieu of U.S. Mail delivery3. lnsured Code found in the lnsured section on the enclosed certificate. An example of this code is XXXXXX-o14. This Certificate Number: 87292691
To learn more about the lnsurance and Risk Management Services offered by Gallagher, please visit us at
www.4g.com/us/a bouGus/how-we-work/core-350.
Gallagher does not share your e-mail as detailed in our privacy policy found at https://www.ajg,com/us/privacy-polacy/
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STATEcoMtr!NsalroNiNSUH^NC'
CERTHOLOER COPY
P,O, BOX 8192, PLEASANTON, CA 94588
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
SP
ISSUE DATE : 01-01-2022
EMPLOYER
VANOERHULE, OANIEL B 0BA: ROOFTEK ROoFING &
T'ATERPROOF ING
3155A RAILROAD CANYON RO STE 2
CANYON LAXE CA 9258?
GROUP:
POLTCY NUMBER 9 r 49583-2022
CERTIFICATE lD: 72
cERTtFtCATE EXPTRES: o',l -ol -2023
o 1 - o 1 -2022 / O 1 -O1 -2023
SP
This is to certity that we have issued a valid \Norkers' Componsation insurance policy in a form approved by tho
Calitornia Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund €xcept upon 36 days advance written notice to the employer
We wrll also give you 30 days advance notice should this policy be cancelled prior to its normel expiration.
This certilicate ol insurance is not an insurance policy and does not amend. extend or alter the coverage atforded
by the policy listed h€rein. Notwithstanding any requirement, term or condition ot any contract or other documentwith respect to which this certiticate of insurance may be issued or to which it may pertain, the insuranc€
allorded by the policy described herein is subject to all the terms, exclusions, and conditions, ot such policy.
CITY OF IiENI FEE
29714 HAUN RO
MENIFEE CA 9258A-6540
/,-".- l-;."-.-
ENOORSEi{ENT '2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE O1-01-2016 IS
ATTACHED TO AND FORl,tS A PART OF THIS POLICY.
/\utho.ized Representative President end CEO
UNLESS INDICATEO OTHERIIISE BY ENOORSEI'ENT, COVERAGE UNDER THIS POLICY EXCLUOES THE FOLLOWING:
THOSE NAMEO IN THE POLICY OECLARATIONS AS AN INOIVIDUAL EIiPLOYER OR A HUSBAND ANO UIFE E"PLOYER;
EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFOROING
CALIFoRNIA TORKERS' COMPENSATION BENEFITS; E|PLoYEES EXCLUDEO UNOER CALIFoRNIA I{ORKERS'
COMPENSATION LAU,
EMPLOYER'S LIAAILITY LIti{IT INCLUOING OEFENSE COSTS: $I,OOO,OOO PER OCCURRENCE,
(REV.7'2014)rxrr{TED : 12- 1A-2021
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