HomeMy WebLinkAboutInsurance Certificate: Footprint Recycling CERTHOLDER COPY NH
STATE CITY RECORDER
COMPENSATION P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807
FUND
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 05-01-2012 GROUP:
POLICY NUMBER: 1844660-2012
CERTIFICATE ID: 1
CERTIFICATE EXPIRES: 05-01-2013
05-01-2012/05-01-2013
CITY OF ASHLAND NH
ATTN: KARI OLSON
90 N MOUNTAIN AVE
ASHLAND OR 97520-2014
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 t0 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.
l'W►NL�. F�
tA,t7hor, edRepresentative President and CEO
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
ENDORSEMENT X0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2011-05-01 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED:
CITY OF ASHLAND
ENDORSEMENT X1600 - COOPER, DAVID A, PRESIDENT - EXCLUDED.
ENDORSEMENT X1600 - KOGER, MICHAEL, VICEPRES - EXCLUDED.
ENDORSEMENT X1600 - FRISBEE, TODD, VICEPRES - EXCLUDED.
_ ENDORSEMENT X1600 - WATERHOUSE, AMY, SEC,TRES - EXCLUDED.
EMPLOYER
FOOTPRINT RECYCLING NH
4701 W END RD X A
ARCATA CA 95521
M0408
IREV.a-20101 PRINTED 04-18-2012