HomeMy WebLinkAboutCOI - Collins, Timothy K. (dba Personal Impressions) - Expires 2021-11-01§if~i=3 COMF>ENSATION INS!JRANCE FUND ISSUE DATE: 05-10-2021 CITY OF GILROY 7301 HANNA ST GILROY CA 95020-6129 CERTHOLDER COPY P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE GROUP: POLICY NUMBER: 9085403-2020 CERTIFICATE ID: 22 CERTIFICATE EXPIRES: 11-01-2021 11-01-2020/11-01-2021 NA This is to certify that we have issued a valid Workers' Compensation 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 conditions, of such policy. ~t!q Ii~,~ xll-e~:~ 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 OR A HUSBAND AND WIFE EMPLOYER; EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS' COMPENSATION LAW. EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2021-05-10 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: ___ CITY OF GILROY EMPLOYER COLLINS, TIMOTHY K DBA: PERSONAL IMPRESSIONS 331 EL CERRITO WAY GILROY CA 95020 (REV.7-2014) PRINTED 05-11-2021 M0408 NA