2018/01/01 Rooftek Roofing and WaterproofingSTATE
FUND
COMPENSATIONINSURANCE
CERTHOLOER COPY
P,O, BOX 8192, PLEASANTON, CA 94588
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
SP
ISSUE DATE: O7 -23-2014
EMPLOYER
VANDERHULE, OANIEL B OBA: ROOFTEK ROOFING &
I{ATERPROOF ING
2399 MSTA t{AY
MENIFEE CA 92587
GBOUP:
POLICY NUMBERT 9149583-2O'i 8
CERTIFICATE lD: 72
CERTTFTCATE EXPIRES O1-Ol -2019
o I -o 1-2018,/ol -ol -2019
CITY OF MENIFEE
29714 HAUN RO
MENIFEE CA 92586-6540
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the
California lnsurence Commissionsr to the employer named below tor the policy period indicEted.
This policy is not subject to cancellation by the Fund except upon 36 days advance written notice to the employer
/-_- t-;"_,.",_
Authorized Representative President and CEO
(FEV.7- 2014)PRINTEo : O7 -24-2018
MO408
We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration.
Ihis certiticate of insurance is not an insurance policy and does not amend, extend or alter the coverage aftorded
by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document
with respect to which this certificate ot insurance may be issued or to which it may pertain, the insurance
atforded by the policy described herein is subject to all the terms, exclusions, and conditions, ot such policy.
SP
UNLESS INOICATED OTHERI{tSE BY ENDORSEI,IENT, COVERAGE UNOER THIS POLICY EXCLUDES THE FOLLOWING:
THOSE NAtilED IN THE POLICY OECLARATIONS AS AN INDMOUAL EIi{PLOYER OR A HUSBAND ANO wIFE EITPLOYER;
EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING
CALIFORNIA I{ORKERS' COMPENSATION BENEFITS; EI'IPLoYEES EXCLUDED UNDER CALIFoRNIA I{ORKERS'
COIIIPENSATION LAt{.
EMPLOYER'S LIABILITY LII{IT INCLUDING DEFENSE COSTS: $I,OOO,OOO PER OCCURRENCE.
ENOORSEiIENT #2065 ENTITLEO CERTIFICATE HOLOERS' NOTICE EFFECTIVE O'i.01-2016 IS
ATTACHED TO AND FORI'S A PART OF THIS POLICY,