HomeMy WebLinkAbout0850-72_Tamarind Avenue Sewer Lift Station_11.2RPR 15 '93 13:13
w.� • — - "P.2/2
STATE P.O. BOX 420807, SAN FRANCISCO -
Q$t37
COMPeNSATION
INSURANCE ' CA 9414
PUN D CERTIFICATE OF WORKERS' COMPENSATION INSURANCEr I993
r
CITY OP FONTANA
DEPT OF BUILDING & SAFETY
P.O. BOX 518
FONTANA, CA 92335
POLICYNUMBEA;1265742 92
CERTIFICATE EXPIRES:
JOB: POR CERTIFICATE PURPOSES
L ONLY BR RAS NO EE' S
ALERT XAVIER RAMIRES IS
This is to certify that we have issued a valid Workers' Compensation insurance pQiicy in a form O pp avOed byR he CaFR lOa niBNENEFITS
Insurance Commissioner to the employer named below for the policy period indicated,
This policy is not subject to cancellation by the Fund except upon ten days' advance written notice to the employer.
We will also give you TEN days' advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the
policies listed herein. Notwithstanding any requirement, .term, or condition of any contract or other document with
respect to which this certificate of insurance may be issued or may pertain, the insurance afforded by the policies
described herein is subject to all the terms, exclusions and conditions of such
policies.
EMPLOYER'S LIABILITY LIMIT:
EMPLOYER
ALBERT XAVIER, RAMIREZ
2322 DONOSA DR.
ROWLAND REIGNS'S CA 91748
L
30130000 Q0p PaR OCCURRENCE.
(FAX•)
/le ‘16e4111/A
PRESIDENT
SCIF 10262 (itEV. 1O-86i)
APR 15 '93 13:12
P.1/2
i 3
COMPEN$AT'iON ARCADIA DISTRICT OFFICE
!NUI ANC FACSIMILE COVER SHEET.
FUND
THIS TRANSMISSION IS FROM A RICOH FX 6OE FACSIMILE UNIT, COMPATIBLE .
WITH GROUPS I! AND III TERMINALS. THIS UNIT 1S OPERATIONAL 24 HOURS DAILY.
` . STATE FUND TELEFAX NUMBER FOR FIELD SERVICES IS
818-574-2649.
DELIVER TO:
DA
FROM:
NAME
COMPANY
TELEMAX NUMBER:. coos
NAME: Stag Cornpensation Insurance Fund
DEPARTMENT : F9.e] Services • •
' PHONE: .(818) 574-2890
eaooOE.
•
' ' MESSAGE: .. Certificate of Insurance
•
'THE TOTAL NUMBER OF, PACES, INCLUDING THIS COVER SHEET, ARE
SHOULD , ANY TRANSMISSION PROBLEMS OCCUR, PLEASE CALL: (818)574,e43 '