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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: XL Specialty Insurance Inception Date: December 31, 2019 <br />Policyholder Name: UNITED STORM WATER, Inc. Expiration Date: December 31, 2020 <br />Policy Number: WEC3001235 <br />Certification <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, Marisa Pina, the undersigned, am , UNITED STORM WATER, INC with the authority to act for and on behalf of the above named <br />contractor. I certify under penalty of perjury that all of the above information provided is true and correct. I further acknowledge that any <br />untruthful information provided in this application could result in the certification being canceled. <br />I certify this on: 6/23/2020 8:44:34 AM <br />Legal Entity Information <br />Legal Entity Type: Corporation <br />Name: UNITED STORM WATER, INC <br />Registration Services:: Page 2 of 2 <br />