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Workers' Compensation <br />Professional Employer Organization (PEO) <br />Do you lease employees through Professional Employer Organization? No <br />Workers' Compensation Overview <br />Insured by carrier <br />Carrier: TRAVELERS PROPERTY Inception Date: June 1, 2017 <br />CASUALTY INSURANCE <br />COMPANY <br />Policyholder Name: GENERAL PUMP COMPANY, Expiration Date: May 30, 2018 <br />INC. <br />Policy Number: PJUB-5946N79-9-16 <br />Certification <br />.. ............ . <br />Yes I certify that I do not have any delinquent liability to an employee or the state for any assessment of back <br />wages or related damages, interest, fines, or penalties pursuant to any final Judgment, order, or determination <br />by a court or any federal, state, or local administrative agency, Including a confirmed arbitration award <br />Yes I certify that the contractor is not currently debarred under Section 1777.1 or under any other federal or state <br />law providing for the debarment of contractors from public works. <br />Yes I certify that one of the following Is true: (1)1 am licensed by the Contractors State License Board (CSLB) In <br />accordance with Chapter 9 (commencing with Section 7000) of the Business and Professions Code; or (2) my <br />business or trade Is not subject to licensing by the CSLB. <br />I understand refunds are not authorized <br />I, Allison Santa Cruz, the undersigned, am , GENERAL PUMP COMPANY, INC. with the authority to act for and on behalf of the above <br />named contractor. I certify under penalty of perjury that all of the above Information provided is true and correct. I further acknowledge <br />that any untruthful Information provided in this application could result In the certification being canceled. <br />I certify this on: 5/24/2019 8:51:18 AM <br />Legal Entity Information <br />Legal Entity Type: Corporation <br />Name: GENERAL PUMP COMPANY, INC. <br />Registration Services:: Page 2 of 2 <br />