PROOF OF INSURANCE (2022 - 2022) CLOSEDDnre(MMlonlrvYrf _.
CERTIFICATE LIABILITY I 10/13/2021
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THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must h P
have ADDITIONAL INSURED rovlslrarris or be onttorsoci.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does
corfificato holster )T1 lieu of such+sndorsumont s
Hot confer rY Iris to the � ., -_ Alan Ghadbia---..-._..m_...�....__�_.... _......_....._
PRODUCER — .. CONTACT n
AVOCO INSURANCE PHONE"
r a,. wtl (818 445 5071„ ykg,twnp_ (800) 552 3562
345 Pioneer Drive NW61L aI rrM , 1larlhi, i moll com
1401 W. I a,tlurtagalsl,nrwoaaawNc a syvrrriAa F NAfC 0
OAV GLGI I Nt3At t CA 91203 tN uRER A NATIONAL IND CO 20087
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INSURED "
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FIVE STAR TRANSPORTATION, INC grgsEqraq:weo;
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1600 Imperial HWY o
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Los Angeles ... _ ..� CA 90ti57 INS UR R r
COVERAGES CERTIFICATE NUMBER:
REVISION NUMBER:
THIS In TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR'FHE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED
BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDI FIONS 017 SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
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b SCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Ramorku Schadula,
may ho aax hod 11 more ePoro le roqulroJ)
Public Transportation. School Bus.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
AUTHORIZED REPRESENTATIVE
RI
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01988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
SEPTEMBER 17, 2021
JACK B. ANDERSON II DBA: FIVE STAR
PO BOX 470323
LOS ANGELES, CA 90047
Dear Policyholder
IN REPLY REFER TO:
9305438-21
Thank you for choosing us as your workers' compensation
insurance carrier.
This package contains your policy contract and new business
documents as listed on the following page. Please keep
these together.
Our goal is to provide you with fast,_ efficient, and the
most convenient service possible. We truly appreciate
your business. If you have any questions about the
information in this mailing; please contact your broker
of record or your local State Compensation Insurance
Fund office.
State Compensation Insurance Fund
5880 Owens Dr . Pleasanton, CA 94588-3900
Mailing Address: P_O. Box 8192 Pleasanton, CA 94588-8792
IMPORTANT - THIS IS NOT A BILL. SEND NO MONEY UNLESS STATEMENT IS ENCLOSED.
HOME OFFICE SAN FRANCISCO POLICY DECLARATIONS
CALIFORNIA WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY POLICY
® THESE DECLARATIONS ARE A PART OF THE WORKERS' COMPENSATION POLICY INDICATED HEREON.
THIS INSURANCE IS EFFECTIVE FROM
12:01 A.M. , PACIFIC STANDARD TIME CONTINUOUS POLICY 9305436-' 21
9 -15-21 TO 9-15-22 AND SHALL
AUTOMATICALLY RENEW EACH 9-15
UNTIL CANCELLED
JACK B. ANDERSON II DBA: FIVE STA DEPOSIT PREMIUM $2,170.00
PO BOX 470323
LOS ANGELES, CALIF 90047 MINIMUM PREMIUM $2,170.00
PREMIUM ADJUSTMENT PERIOD ANNUALLY
N SC
NAME OF EMPLOYER- ANDERSON II, JACK, B. (AND/OR) FIVE STAR
SCHOOL TRANSPORTATION INC (A CORP)
TRADE NAMES- JACK B. ANDERSON II DBA: FIVE STAR
TRANSPORTATION
LOCATIONS- 1081 IMPERIAL'HIGHWAY
LOS ANGELES CA 90047
1. WORKERS' COMPENSATION INSURANCE '- PART ONE OF THIS POLICY APPLIES TO THE
WORKERS' COMPENSATION LAWS OF THE STATE OF CALIFORNIA.
2. EMPLOYER'S LIABILITY INSURANCE - PART TWO OF THIS POLICY APPLIES TO
LIABILITY UNDER THE LAWS OF THE STATE OF CALIFORNIA. THE LIMIT OF OUR
LIABILITY INCLUDING DEFENSE COSTS UNDER PART TWO IS,
CODE NO.
7382-1
$1,000,000
PRINCIPAL WORK AND RATES EFFECTIVE FROM 09-15-21 TO 09-15-22
BUS, SHUTTLE VAN OR LIMOUSINE OPERA-
TIONS --ALL EMPLOYEES
INTERIi
PREMIUM BASE BILLING
BASIS RATE RATE-
5600 15.19 20.91
********BUREAU NOTE INFORMATION********
JACK B. ANDERSON P,S,T 100.00 %
FEIN 383717012
TOTAL ESTIMATED ANNUAL PREMIUM $2,170
COUNTERSIGNED AND ISSUED AT SAN FRANCISCO SEPTEMBER 17, 2021 POLICY L PAGE 1 OF 3