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CERTHOLDER COPY P.O. BOX 420807, SAN FRANCISCO,CA 84142 -0807 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 06 -01 -2012 CITY OF RIVERSIDE 3900 MAIN ST RIVERSIDE CA 92522 -0001 3J POLICY NUMBER: 1680407 -2012 CERTIFICATE ID: 5 CERTIFICATE EXPIRES: 06 -01 -2013 05 -01- 2012/06 -01 -2013 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 30 days advance written notice to the employer. We will also give you 30 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. 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 #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 06 -01 -2011 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER GEORGE LIBLIN DBA: G &F TRAILER REPAIR 2175 S WILLOW AVE BLOOMINGTON CA 92316 Si sJ M0408 IREV.8 -2010) PRINTED : 05 -17 -2012