2022/07/15 Rolcom, Inc.o.fu
COVERAGES
CERTIFICATE OF LIABILITY INSURANCE
CERTIFICATE NUMBER: 00001305-24194 REVISION NUMBER: 57
THIS CERTIFICATE IS ISSUED AS A iTATTER OF INFORMATION O}ILY ANO CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE OOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFOROED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING ITISURER(S), AUTHORIZEO
REPRESENTATIVE OR PRODUCER, AI'ID THE CERTIFICATE HOLDER.
IMPORTANT: lf tho cortlflcato holder ls an ADDITIONAL INSURED, tho pollcy(los) must havo AODITIONAL INSURED provislons or bs endorsad.
l, SUBROGATION lS WAIVEO, subject to the terms and condltlons ot the pollcy, cortaln pollclos may rgquire an endorsoment. A slatomont on
thls ce.tltlcato doos not confo lghts to the cortiflcate holder ln lieu of Euch ando6smontls).
PRoDU.ER ELG lnsurance services, LLc
1230 N. Jefferson Street, Unit B
Anaheim, CA 92807
License #: 0D0172'l
Ste hanie or
PHONE 4 551-9920 14 4,11"8795
Ste hM lnsutanco.com
rNsuRe AFFOROING COVERAGE
rr.rsunena, Ohio Securiw lnsurance Comoanv 24082
INSURED
Rolcom, lnc.
240 ott st
Corona, CA 92882
INSURER B
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREO NAMED AEOVE FOR THE POLICY PERIOD
INDICATEO, NOTWTHSTANDING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER OOCUMENT WTH RESPECT TO VVTIICH lHIS
CERTIFICATE MAY 8E ISSUED OR MAY PERTAIN, THE INSURANCE AFFOROEO BY THE POLICIES DESCRIBEO HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONOITIONS OF SUCH POLICIES. LIMITS SHO\.{1{ MAY HAVE SEEN REOUC€D BY PAID CLAIMS.
INSR L MITS
COMM€RCIAI GENERAL LTABIIITY
CLAIMS-MAOE
GEN'L AGGREGATE LIMIT APPL ES PER
POLICY
OTHER
EIE& Erc"
EACH OCCURRENCE s
OAMAGE TO RENTEOPRFMISFS rFa sod.n.!l 5
ME0 EXP (Any one perso.)5
PERSONAL &ADV]NJURY 5
GENERAL AGGREGATE s
PROOUCTS . COMP/OP AGG 5
t
AUTOMOBILE LIABIL Y
OWNEO
AU'TOS ONLY
H REO
AUTOS ONLY
SCHEDULEOAUTOS
NON.OV\NED
AUTOS ONLY
s
BOD LY TNJURY (P€r p€rson)$
BOD LY NJURY (P6r a@denl)s
$
$
U AREILALIAB
EXCESSLIAB
OCCUR
CLAIMS.MADE
EACH OCCURRENCE s
AGGREGATE 5
OED RETENTION S s
woRxEis coMPENsanoal
ANO EIIPIOYERS' UABILIIY
ANY PROPRIE-IORFARiNER]':XECUiIVE
OFFICERn,lEMBEi EXCLUOEO?
OESCRIPTTON OF OPERAITONS b6rtu
xws63608430 o7115t2022 07 t15t2023 X MI"".ofH
E L E:ACTIACC]DENT s 1,000,000
E L OISEASE - EA EMPLOYEE s I,000,000
E L OISEASE. POLICY LIM 1 s I,000,000
oESCRIPTTON OF OPERATIO|I S / LOCA-ITONS / VEHICLES (ACORO 101 , Addldon.l Rom.,l! Sch.dulo, m.y b. rtt chod lr moE 3p.c. l. eqlled)
CERIIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE OESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATIOTI OATE THEREOF, NOTICE wlLL BE DELIVEREO IN
ACCORDANCE wlTH THE POLICY PROVISIONS.
(scr'r)
@ 1988-2015 ACORD CORPORATION. All rlghls reserved
The ACORD name and logo aro registered marks of ACORO Printed by SCM on 07/05/2022 at 02:36PMACORO 25 (2016/03)
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A
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City of Menifee
Engineering Department
29714 Heun Road
Menifee, CA 92586
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY wc 99 06 79
(Ed.01-13)
-G
:
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
. CALIFORNIA
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will
not enforce our right against the person or organization named in the Schedule. (This agreement applies
only to the extent that you perform work under a written contract that requires you to obtain this agreement
from us.)
You must maintain payroll records accurately segregating the remuneration of your employees while en-
gaged in the work described in the Schedule.
The additional premium for this endorsement is $ 250
Schedule
Person or Organization
Where requj.red by contract or written agreement
Job Description
This endorsemsnt changes the policy to which it is attached and is effeclive on the date issued unless
otheMise stated.
(The information below is required only when this endorsement is issued subsequent to preparation of
the policy.)
Endorsement Effective Endorsement No. 0007
Policy Effective 0711512022 Premium
State
Policy No. XWS (23) 63 60 84 30
lnsured ROLCOM INC
wc 99 06 79
(Ed.01-13)
o 2013 Liberty i,4utual lnsurance
lncludes copyrighted material ol WClRBwith its permission
a
E
19291lnsurance Company Ohio Security lnsurance Company
Countersigned by
wc 99 06 79
(Ed.01-13)
-EE''
E-
E!
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON AND WYOMING
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will
not enforce our right against the person or organization named in the Scheduls. (This agreement applies
only to the extent that you perform work under a written contract lhat requires you to obtain this agreement
from us.)
You must maintain payroll records accurately segregating the remuneration of your employees while en-
gaged in the work described in the Schedule.
The additional premium for this endorsement is $ 250
Schedule
Person or Organization
Where reguired by contract or written agreemenE
prior to loss and allowed by law.
This endorsement
otheMise stated.
changes the policy to which it is attached and is effective on the date issued unless
(The information below is required only when this endorsement is issued subsequent to preparation of
the policy.)
Endorsement Effective Endorcement No. 0009
Policy Effective 07l'1512022 Premium
State
Policy No. XWS (21) 63 60 84 30
lnsured ROLCOM INC
lnsurance Company Ohio Security lnsurance Company
Countersigned by
wc 99 06 79
(Ed.01-13)
o zot3 Liberty Mutual lnsuranca
lncludes copyrighted material of WClRB,with its permission
3
19291
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
Job Description