Common use of COMPENSATION INSURANCE CERTIFICATE Clause in Contracts

COMPENSATION INSURANCE CERTIFICATE. The CONTRACTOR shall execute the following form as required by the California Labor Code, Sections 1860 and 1861: I am aware of the provisions of Section 3700 of the Labor Code which require every employer to be insured against liability for workers’ compensation or to undertake self-insurance in accordance with the provisions of that code, and I will comply with such provisions before commencing the performance of the work of this contract. DATE: ALL AMERICAN ASPHALT By: (Signature) (Title) Attest: By: (Signature) (Title) NOTE: See Section 7 Responsibility of the CONTRACTOR, Paragraph 7-3 of the Standard Specifications for insurance carrier rating requirements. THIS PAGE LEFT INTENTIONALLY BLANK ENDORSEMENTS TO INSURANCE POLICY Name of Insurance Company: Policy Number: Effective Date: The following endorsements are hereby incorporated by reference into the attached Certificate of Insurance as though fully set forth thereon:

COMPENSATION INSURANCE CERTIFICATE. The CONTRACTOR shall execute the following form as required by the California Labor Code, Sections 1860 and 1861: I am aware of the provisions of Section 3700 of the Labor Code which require every employer to be insured against liability for workers’ compensation or to undertake self-insurance in accordance with the provisions of that code, and I will comply with such provisions before commencing the performance of the work of this contract. DATE: ALL AMERICAN ASPHALT XXXXX GENERAL ENGINEERING CONTRACTORS, INC By: (Signature) (Title) Attest: By: (Signature) (Title) NOTE: See Section 7 Responsibility of the CONTRACTOR, Paragraph 7-3 of the Standard Specifications for insurance carrier rating requirements. THIS PAGE LEFT INTENTIONALLY BLANK ENDORSEMENTS TO INSURANCE POLICY Name of Insurance Company: Policy Number: Effective Date: The following endorsements are hereby incorporated by reference into the attached Certificate of Insurance as though fully set forth thereon:

COMPENSATION INSURANCE CERTIFICATE. The CONTRACTOR shall execute the following form as required by the California Labor Code, Sections 1860 and 1861: I am aware of the provisions of Section 3700 of the Labor Code which require every employer to be insured against liability for workers’ compensation or to undertake self-insurance in accordance with the provisions of that code, and I will comply with such provisions before commencing the performance of the work of this contract. DATE: ALL AMERICAN ASPHALT By: :_ (Signature) (Title) Attest: By: :_ (Signature) (Title) NOTE: See Section 7 Responsibility of the CONTRACTOR, Paragraph 7-3 of the Standard Specifications for insurance carrier rating requirements. THIS PAGE LEFT INTENTIONALLY BLANK ENDORSEMENTS TO INSURANCE POLICY Name of Insurance Company: Policy Number: Effective Date: The following endorsements are hereby incorporated by reference into the attached Certificate of Insurance as though fully set forth thereon:

COMPENSATION INSURANCE CERTIFICATE. The CONTRACTOR shall execute the following form as required by the California Labor Code, Sections 1860 and 1861: I am aware of the provisions of Section 3700 of the Labor Code which require every employer to be insured against liability for workers’ compensation or to undertake self-insurance in accordance with the provisions of that code, and I will comply with such provisions before commencing the performance of the work of this contract. DATE: ALL AMERICAN ASPHALT Xxxxx-Xxxxxx Contracting Company By: (Signature) (Title) Attest: By: (Signature) (Title) NOTE: See Section 7 Responsibility of the CONTRACTOR, Paragraph 7-3 of the Standard Specifications for insurance carrier rating requirements. THIS PAGE LEFT INTENTIONALLY BLANK ENDORSEMENTS TO INSURANCE POLICY Name of Insurance Company: Policy Number: Effective Date: The following endorsements are hereby incorporated by reference into the attached Certificate of Insurance as though fully set forth thereon: