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Home My WebLink AboutExhibit C- Exemption from Workers CompensationEXHIBIT "C" EXEMPTION FROM WORKERS COMPENSATION CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE I hereby certify that in the performance of the work for which this Agreement is entered into, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of the State of California Executed on this day of = 201J at`� California. Consu ant A °® CERTIFICATE OF LIABILITY INSURANCE Page 1 of 2 08/29/2 11 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Willis of Massachusetts, Inc. 26 Century Blvd. P. O. Box 305191 PHONE FAX 877- 945 -7378 888 - 467 -2378 E -MAIL certificates@willis.com Nashville, TN 37230 -5191 INSURER(S)AFFORDINGOOVERAGE NAIC # INSURERA:National Union Fire Insurance Company of 19445 -001 EACH OCCURRENCE INSURED IIniFirst Corporation and its Subsidiaries INSURERB:New Hampshire Insurance Company 23841 -004 INSURERC:The Insurance Company of the State of Pen 19429 -001 68 Jonspin Road Wilmington, MA 01887 INSURER D:Chartia Casualty Company, USA 40256 -001 INSURER E: MED EXP (Any one person) $ 51000 INSURER F: $ 11000,000 COVERAGES CERTIFICATE NUMBER: 16428619 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPEOFINSURANCE DD' SUB pOLICYNUMBER POLICY EFF POLICY EXP LIMITS A GENERAL LIABILITY Y Y 4360909 10/1/2010 10/1/2011 EACH OCCURRENCE $ 11000,000 PREMISES Eaoccureence $ 11000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR MED EXP (Any one person) $ 51000 PERSONAL& ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 GE IAGGREGATELIMITAPPLIESPER: PRODUCTS - COMP /OPAGG $ 2,000,000 $ X POLICY PRO- LOC FQT B AUTOMOBILE LIABILITY Y Y ADS 3976593 10/1/2010 10/1/2011 COMBINED SINGLE LIMIT (Ea accident) $ 2,000,000 BODILY INJURY(Per person) $ B X ANYAUTO Y Y MA 3976594 10/1/2010 10/1/2011 B ALLOWNED SCHEDULED AUTOS AUTOS HIREDAUTOS NON -OWNED AUTOS Y Y VA 3976811 10/1/2010 10/1/2011 BODILY INJURY(Per accident) $ PROPERTY DAMAGE (Peraocident) $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I RETENTION $ $ A C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR /PARTNER/EXECUTIVEY� N/A y Y MA,ME,OH 1192338 CA 026149566 10/1/2010 10/1/2010 10/1/2011 10/1/2011 X E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE -EA EMPLOYEE $ 1,000,000 B B OFFICER/MInNH) EXCLUDED? Nlandatory in NH) fy fyes,descnbeunder DESCRIPTION OF OPERATIONS below Y ADS 026149568 MN, NY,WI 026149569 10/1/2010 10/1/2010 10/1/2011 10/1/2011 E.L. DISEASE - POLICY LIMIT $ 1,000,000 B C B Worker's Comp WC- statutory limits Eyyy FL 026149570 OR 026149571 TX 026149572 10/1/2010 10/1/2010 10/1/2010 101 /1/201 10/1/2011 10/1/2011 $1,000,000 EL each accident $1,000,000 EL disease each employee $1,000,000 EL disease policy limit D AOS 0 26149567 10/1/2010 10/1/2011 DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (Attach Acord 101, Additonal Remarks Schedule, if more space is required) Division /Location: 325 Certificate Holder is an Additional Insured for General Liability and Auto Liability as their interest may appear if required by written contract but only with respect to liability arising out of operations of the Named Insured. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE City of Lake Elsinore 130 South Main Street Lake Elsinore, CA 92530 Coll:3470585 Tp1:1149657 Cert:16428619 U 1988- ZUlUACURDCORPURATIUN . All rigntsreserVea. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC #: A400RO® ADDITIONAL REMARKS SCHEDULE Paged of AGENCY NAMEDINSURED Willis of Massachusetts, Inc. UniFirst Corporation and its Subsidiaries 68 Jonspin Road Wilmington, MA 01887 POLICY NUMBER See First Page CARRIER NAIC CODE I EFFECTIVEDATE: See First Page See First Page ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE It is understood and avreed that the Company Waives its right of Subrogation against the Additional Insureds which may arise by reason of a payment of claim under all the policies, if required by written contract and as permitted by law. Additional Insured: City of Lake Elsinore. ACORD 101(2008 /01) Coll:3470585 Tpl:1149657 cert:1b4ZUbly VLUUBHI. VRLJVVRPVRAIivrv.Hnnynwcacvcu. The ACORD name and logo are registered marks of ACORD