1996-0911_EMPIRE PIPE CLEANING & EQUIPMENT_Workers Comp Insurance • '''' .GOLDEN EAGLE INSURANCE COMPANY
P.O. Box 85826 - San Diego, CA 92186-5826
WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY
REINSTATEMENT NOTICE Policy No: NWC-336062-03
01-05039
Reinstatement Effective: 09/11/96 at 12:01 A.M. Standard Time
Date Mailed: SEP 1mailed From: San Dieeo CA 92119
It is understood and agreed that the policy for the number shown above and issued by the company named above is
hereby reinstated effective on the reinstatement effective date shown hereon.
By:
Named Insured:
EMPIRE PIPE CLEANING & EQUIPMENT, INC .
P.O. BOX 8035
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Agent:
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BOSWELL INS . AGENCY, AGENTS & BROKERS** -0
25411 CABOT RD. , #206 nr,o
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LAGUNA HILLS CA 92653 -�n P1
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Certificate Holder:
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ATTN: CITY CLERK n
CITY OF SAN JUAN CAPISTRANO 0-0/(1Y167o /'"��F
32400 PASEO ADELANTO / ✓
SAN JUAN CAPISTRAN CA 92675—
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GOLDEN EAGLE INSURANCE COMPANY
P.O. Box 85826 - San Diego, CA 92186-5826
WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY
NOTICE OF CANCELLATION Policy No: NWC-336062-03
Cancellation Effective; 09/11/96 at 12:01 A.M. Standard Time
Date Mailed: 08/28/96 Mailed From: San Diego CA 92119
® You are hereby notified in accordance with the terms and conditions of the policy mentioned above that your insurance
will cease at and from the hour and date mentioned hereon. If the premium has been paid, premium adjustment will be
made as soon as practicable after cancellation becomes effective. If the premium has not been paid, a bill for the
premium earned to the time of cancellation will be forwarded in due course.
❑ *You are hereby advised that California law provides that upon request in writing made by you to this
Company, such request to be mailed or delivered not less than 15 days prior to the date of cancellation, you
are entitled to be informed by this Company in writing of the reason(s) for the cancellation.
❑ *The reason for cancellation is Paragraph(s) of California Insurance Code Section 676. Upon
written request of the named insured, the insurer will furnish the facts on which the cancellation is based.
*Not applicable to Commercial Lines. These boxes will not be checked unless a California law is applicable.
❑ You are hereby notified in accordance with the terms and conditions of the policy mentioned below that your insurance
will cease at and from the hour and date mentioned above due to nonpayment of premium. A bill for the premium
earned to the time of cancellation will be forwarded in due course
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Named Insured: Reason for CancellaiH" 3 v
EMPIRE PIPE CLEANING & EQUIPMENT, INC. 10 ❑Rewritten by:
P.O. BOX 8035 20❑Agent's Request
ANAHEIM Cr.. 92202 23 u bVUttay A
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30 ❑Non-Payment of$
on Policy:
Agent: 31 ❑Non-Payment of Deposit
BOSWELL INS . AGENCY, AGENTS & BROKERS** 33 ❑Non-Payment Finance Company
25411 CABOT RD. , #206 40®Non-Report of Payroll Values:
LAGUNA HILLS CA 92653 / 07/G1/96to 08/01/96
tS�/Oa- on Policy: NWC-336062-03
/3O/q6 : x t ' i as of: 08/24/96
?fY-` 60 El Insured's Request
re_Certificate Holder: �--rn e 112-270❑Company Election
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ATTN: CITY CLERK f etteL //Out be 80 El Policy Not Accepted
CITY OF SAN JUAN CAPISTRANO read 90❑Policy Issued in Error
32400 PASEO ADELANTOJ ,,^�
SAN JUAN CAPISTRAN CA 92675— JA YI�_L
UWoo1 �zis1) Cert Holder Copy
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