C. The following is added and supersedes any provi
sions to the contrary:
NONRENEWAL
1. Subject to the provisions of Paragraphs C.2.
and C.3. below, if we elect not to renew this
policy, we will mail or deliver written notice stat
ing the reason for nonrenewal to the first
Named Insured shown in the Declarations and
to the producer of record, at least 60 days, but
not more than 120 days, before the expiration
or anniversary date.
We will mail or deliver our notice to the first
Named Insured, and to the producer of record,
at the mailing address shown in the policy.
2. Residential Property
This provision applies to coverage on real
property used predominantly for residential
purposes and consisting of not more than four
dwelling units, and to coverage on tenants'
household property contained in a residential
unit, if such coverage is written under one of
the following:
Capital Assets Program (Output Policy) Cover
age Part
Commercial Property Coverage Part
Farm Coverage Part - Farm Property - Farm
Dwellings, Appurtenant Structures And House
hold Personal Property Coverage Form
a. We may elect not to renew such coverage
for any reason, except as provided in b., c.
and d. below:
b. We will not refuse to renew such coverage
solely because the first Named Insured has
accepted an offer of earthquake coverage.
However, the following applies only to in
surers who are associate participating in
surers as established by Cal. Ins. Code
Section 10089.16. We may elect not to re
new such coverage after the first Named
Insured has accepted an offer of earth
quake coverage, if one or more of the fol
lowing reasons applies:
(1) The nonrenewal is based on sound
underwriting principles that relate to the
coverages provided by this policy and
that are consistent with the approved
rating plan and related documents filed
with the Department of Insurance as re
quired by existing law;
(2) The Commissioner of Insurance finds
that the exposure to potential losses will
threaten our solvency or place us in a
hazardous condition. A hazardous con
dition includes, but is not limited to, a
condition in which we make claims
payments for losses resulting from an
earthquake that occurred within the pre
ceding two years and that required a re
duction in policyholder surplus of at
least 25% for payment of those claims;
or
(3) We have:
(a) Lost or experienced a substantial
reduction in the availability or scope
of reinsurance coverage; or
(b) Experienced a substantial increase
in the premium charged for reinsur
ance coverage of our residential
property insurance policies; and
the Commissioner has approved a plan
for the nonrenewals that is fair and
equitable, and that is responsive to the
changes in our reinsurance position.
c. We will not refuse to renew such coverage
solely because the first Named Insured has
cancelled or did not renew a policy, issued
by the California_Earthquake AuthoriJy that~~
included an earthquake policy premium
surcharge.
d. We will not refuse to renew such coverage
solely because corrosive soil conditions ex
ist on the premises. This Restriction (d.)
applies only if coverage is subject to one of
the following, which exclude loss or dam
age caused by or resulting from corrosive
soil conditions:
(1) Capital Assets Program Coverage Form
(Output Policy);
(2) Commercial Property Coverage Part -
Causes Of Loss - Special Form; or
(3) Farm Coverage Part - Causes Of Loss
Form - Farm Property, Paragraph D.
Covered Causes Of Loss - Special.
3. We are not required to send notice of nonre
newal in the following situations:
a. If the transfer or renewal of a policy, without
any changes in terms, conditions, or rates,
is between us and a member of our insur
ance group.
IL 02 70 09 08 © ISO Properties, Inc., 2007 Page 3 of 4 b. If the policy has been extended for 90 days
or less, provided that notice has been given
in accordance with Paragraph C.1.
c. If you have obtained replacement coverage,
or if the first Named Insured has agreed, in
writing, within 60 days of the termination of
the policy, to obtain that coverage.
d. If the policy is for a period of no more than
60 days and you are notified at the time of
issuance that it will not be renewed.
e. If the first Named Insured requests a
change in the terms or conditions or risks
covered by the policy within 60 days of the
end of the policy period.
f. If we have made a written offer to the first
Named Insured, in accordance with the
timeframes shown in Paragraph C.1., to re
new the policy under changed terms or
conditions or at an increased premium rate,
when the increase exceeds 25%.
~'t'
HISCOX
Policy Number: P101.473.493.1
Named Insured: Richard Yau
Endorsement Number: 17
Endorsement Effective: 01/31/2023
Hiscox Insurance Company Inc.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CALIFORNIA CHANGES
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
The term "spouse" is replaced by the following:
Spouse or registered domestic partner under Califor
nia law.
CG 32 34 01 05 © ISO Properties, Inc., 2004 Page 1 of 1 ~'"' HISCOX Hiscox Insurance Company Inc.
Policy Number:
Named Insured:
Endorsement Number:
Endorsement Effective:
P101.473.493.1
Richard Yau
18 01/31/2023
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARY AND NONCONTRIBUTORY - OTHER
INSURANCE CONDITION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
A. The following is added to the Other Insurance
Condition and supersedes any provision to the
contrary:
Primary And Noncontributory Insurance
This insurance is primary to and will not seek
contribution from any other insurance available
to an additional insured under your policy, pro
vided:
1. you have agreed in a written contract or
agreement to add such additional insured to
a policy providing the type of coverage af
forded by this policy; and
2. you have agreed in a written contract or
agreement with such additional insured that
this insurance would be primary and would
not seek contribution from any other insur
ance available to the additional insured.
CGL E5581 CW (03/16) Includes copyrighted material of
Insurance Services Office, Inc., with its permission
~'ti
HISCOX
Policy Number: P101.473.493 .1
Named Insured: Richard Yau
Endorsement Number: 19
Endorsement Effective: 01/31/2023
Hiscox Insurance Company Inc.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
HIRED AUTO AND NON-OWNED AUTO LIABILITY
This endorsement modifies insurance provided under the following :
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Coverage Limit of Insurance
Hired/Non-owned auto $1,000,000 each occurrence liability The Limit of Insurance shown above will be subject to, and will not increase, the General Aggregate Limit applicable to the Commercial General Liability Coverage Part.
If no information is stated above, the relevant information to complete the Schedule will be shown in the Declarations .
A. The coverage provided by this endorsement will
apply only up to the Limit of Insurance specified
above or in the Declarations, if no information is
shown in the Schedule.
1. Hired Auto Liability
The coverage provided under Coverage A -
Bodily Injury and Property Damage Liability
in Section I - Coverages applies to "bodily
injury" or "property damage" arising out of the
maintenance or use of a "hired auto" by you or
your "employees" in the course of your
business.
2. Non-owned Auto Liability
The coverage provided under Coverage A -
Bodily Injury and Property Damage Liability
in Section I - Coverages applies to "bodily
injury" or "property damage" arising out of the
maintenance or use of any "non-owned auto"
in your business by any person.
B. With respect to the coverage provided by this
endorsement only, the following apply:
1. The exclusions under Paragraph 2.
Exclusions in Coverage A - Bodily Injury
and Property Damage Liability in Section I -
Coverages, other than Exclusions a., b., d., f.,
and i. are deleted in their entirety, and
exclusions e. and j. are replaced by the
following :
hn-e. Employer's Liability
"Bodily injury" to:
(1 )An "employee" of the insured arising out of
and in the course of:
(a) Employment by the insured; or
(b) Performing duties related to the conduct
of the insured's business; or
(2) The spouse, child, parent, brother or sister
of that "employee" as a consequence of
Paragraph (1) above.
This exclusion applies:
(1) Whether the insured may be liable as an
employer or in any other capacity ; and
CGLE 5691 CW (11 /19) Includes copyrighted material of Insurance Services Offices, Inc., with its permission Page 1 of 2 (2) To any obligation to share damages with
or repay someone else who must pay
damages because of injury.
This exclusion does not apply to:
(i) Liability assumed by the insured under an
"insured contract"; or
(ii)"Bodily injury" arising out of and in the
course of domestic employment by the
insured unless benefits for such injury are in
whole or in part either payable or required to
be provided under any workers' compensa
tion law.
hn-j. Damage to Property
"Property damage" to:
(1) Property owned or being transported by, or
rented or loaned to the insured; or
(2)Property in the care, custody, or control of
the insured.
2. Section II - Who Is An Insured is deleted in
its entirety and replaced by the following:
Each of the following is an insured under this
endorsement to the extent set forth below:
a. You;
b. Any other person using a "hired auto" with
your permission;
c. Solely for a "non-owned auto":
(1) Any partner or "executive officer" of
yours; or
(2) Any "employee" of yours; but only while
such "non-owned auto" is being used in
your business; and
d. Any_ ot_he~ person or organization , but only
for their hab1l1ty because of acts or omissions
of an insured under a., b. or c. above.
None of the following will be considered an
insured under this endorsement:
(1) Any person engaged in the business of
their employer for "bodily injury" to any co
"employee" of such person injured in the
course of employment , or to the spouse, child,
parent, brother, or sister of that co-"employee"
as a consequence of such "bodily injury", or for
any obligation to share damages with or repay
someone else who must pay damages
because of the injury;
(2) Any partner or "executive officer" for any
"auto" owned by such partner or officer or a
member of his or her household;
(3) Any person while employed in or otherwise
engaged in duties in connection with an
"auto business", other than an "auto
business" you operate;
(4) The owner or lessee (of whom you are a
sublessee) of a "hired auto" or the owner of
a "non-owned auto" or any agent or
"employee" of any such owner or lessee; or
(5) Any person or organization for the conduct
of any current or past partnership or joint
venture that is not shown as a Named
Insured in the Declarations .
C. For purposes of this endorsement only, Section Ill
- Limits of Insurance is amended to the extent
necessary to provide the following:
Regardless of the number of "hired autos " "non
owned autos", or vehicles involved, or the 'number
of claims made or "suits" brought, the most we will
pay for all damages resulting from any one
"occurrence" covered under this endorsement will
be the Limit of Insurance stated in the Schedule
above.
Al! payments we make for damages covered by
this endorsement will be a part of, and not in
addition to, the General Aggregate Limit stated in
the Declarations.
D. For the purposes of this endorsement only, 4.
Other Insurance in Section IV - Commercial
General Liability Conditions is deleted in its
entirety and replaced by the following:
T~is ins~rance is specifically excess over any
primary insurance covering the "hired auto" or
"non-owned auto".
D. With respect to the coverage provided by this
endorsement , the following additional definitions
are added to Section V- Definitions:
1. "Auto business" means the business or occu
pation of selling, repairing, servicing , storing, or
parking "autos".
2. "Hired auto" means any "auto" you lease, hire,
rent, or borrow. "Hired auto" does not include
any "auto" you lease, hire, rent, or borrow from
any of your "employees", your partners, or your
"executive officers", or members of their house
holds.
3. "Non-owned auto" means any "auto" you do
not own, lease, hire, rent, or borrow which is
used in connection with your business. This in
cludes "autos" owned by your "employees" ,
your partners, or your "executive officers", or
members of their households , but only while
used in your business or your personal affairs.
cGTI5ff9f"CWT1 '!Tf9} lnclu es copyrignted material of Ins ran Services Offices, Inc., with its permission Page 2 of 2 ~'"' HISCOX
Policy Number:
Named Insured:
Endorsement Number:
Endorsement Effective:
P101.473.493.1
Richard Yau
20 01/31/2023
Hiscox Insurance Company Inc.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
EXCLUSION OF CERTIFIED ACTS OF TERRORISM
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
A. The following exclusion is added:
This insurance does not apply to:
TERRORISM
"Any injury or damage" arising, directly or indirect
ly, out of a "certified act of terrorism".
B. The following definitions are added:
1. For the purposes of this endorsement, "any
injury or damage" means any injury or damage
covered under any Coverage Part to which this
endorsement is applicable, and includes but is
not limited to "bodily injury", "property dam
age", "personal and advertising injury", "injury"
or "environmental damage" as may be defined
in any applicable Coverage Part.
2. "Certified act of terrorism" means an act that is
certified by the Secretary of the Treasury, in
accordance with the provisions of the federal
Terrorism Risk Insurance Act, to be an act of
terrorism pursuant to such Act. The criteria
contained in the Terrorism Risk Insurance Act
for a "certified act of terrorism" include the fol
lowing:
a. The act resulted in insured losses in excess
of $5 million in the aggregate, attributable to
all types of insurance subject to the Terror
ism Risk Insurance Act; and
b. The act is a violent act or an act that is
dangerous to human life, property or infra
structure and is committed by an individual
or individuals as part of an effort to coerce
the civilian population of the United States
or to influence the policy or affect the con
duct of the United States Government by
coercion.
C. The terms and limitations of any terrorism exclu
sion, or the inapplicability or omission of a terror
ism exclusion, do not serve to create coverage for
injury or damage that is otherwise excluded under
this Coverage Part.
CG 21730115 © Insurance Services Office, Inc., 2014 Page 1 of 1 fl).I"
HISCOX
encourage courage •
Notices
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HISCOX
Policyholder Notice
Electronic Delivery
If you received your insurance policy by email, it is because you have chosen electronic delivery of your policy documents and important notices, including cancellation and nonrenewal notices where permitted by law. We also will send any renewal policy documents to you by email at the address you have provided.
If you are currently receiving paper documents and would like to have ease of retrieval and access and save on storage space, you will need to contact us and update your preferences. Most documents can be sent electronically within minutes. For electronic documents, you will need a computer or mobile device with Internet access and the ability to receive external emails. You also will need software such as Adobe Reader® that allows you to view and save PDF documents, and a printer to create paper copies.
At any time you may request a paper copy of your policy, or you may withdraw your consent to receive documents by email. We will then send documents to you by US mail at no added cost.
You must notify us if your email or street address changes . To update your email or street address , or to request paper documents, please contact us at 888-202-3007.
INT N003 CW (01/19)
~'fl
HISCOX Hiscox Insurance Company Inc.
ECONOMIC AND TRADE SANCTIONS POLICYHOLDER NOTICE
Hiscox is committed to complying with the U.S. Department of Treasury Office of Foreign Assets Control (OFAC) requirements. OFAC administers and enforces economic sanctions policy based on Presidential declarations of national emergency . OFAC has identified and listed numerous foreign agents, front organizations, terrorists , and narcotics traffickers as Specially Designated Nationals (SDN's) and Blocked Persons. OFAC has also identified Sanctioned Countries. A list of Specially Designated Nationals , Blocked Persons and Sanctioned Countries may be found on the United States Treasury's web site http://www.treas .gov/offices/enforcement/ofac /.
Economic sanctions prohibit all United States citizens (including corporations and other entities) and permanent resident aliens from engaging in transactions with Specially Designated Nationals , Blocked Persons and Sanctioned Countries. Hiscox may not accept premium from or issue a policy to insure property of or make a claim payment to a Specially Designated National or Blocked Person. Hiscox may not engage in business transactions with a Sanctioned Country.
A Specially Designated National or Blocked Person is any person who is determined as such by the Secretary of Treasury.
A Sanctioned Country is any country that is the subject of trade or economic embargoes imposed by the laws or regulations of the United States.
In accordance with laws and regulations of the United States concerning economic and trade embargoes , this policy may be rendered void from its inception with respect to any term or condition of this policy that violates any laws or regulations of the United States concerning economic and trade embargoes including, but not limited to the following:
(1) Any insured under this Policy, or any person or entity claiming the benefits of such insured, who is or becomes a Specially Designated National or Blocked Person or who is otherwise subject to US economic trade sanctions ;
(2) Any claim or suit that is brought in a Sanctioned Country or by a Sanctioned Country government , where any action in connection with such claim or suit is prohibited by US economic or trade sanctions; (3) Any claim or suit that is brought by any Specially Designated National or Blocked Person or any person or entity who is otherwise subject to US economic or trade sanctions ; (4) Property that is located in a Sanctioned Country or that is owned by, rented to or in the care , custody or control of a Sanctioned Country government , where any activities related to such property are prohibited by US economic or trade sanctions ; or
(5) Property that is owned by, rented to or in the care, custody or control of a Specially Designated National or Blocked Person, or any person or entity who is otherwise subject to US economic or trade sanctions.
Please read your Policy carefully and discuss with your broker/agent or insurance professional. You may also visit the US Treasury's website at http://www.treas.gov/offices/enforcement/ofac/.
INT N001 CW 01 09 Page 1 of 1
"'~ HISCOX
encourage courage •
Application Summary
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HISCOX
encourage courage• Hiscox Insurance Company Inc.
Application Summary
The following outlines the details you have given us about your business. We have relied on the accuracy of this information in order to issue your policy. If any of the items below are incorrect or have changed, please call us at so that we can update your policy details.
Your policy
Policy number:
Quote reference number:
Product:
Business name:
Business address:
City:
State:
Zip code:
County:
Name:
Email address:
Telephone number:
Per occurrence limit of liability:
Aggregate limit of liability:
Deductible:
Revenue:
When would you like your policy to start?
Locations
Covered Location 1:
Revenue:
Your business
Class of Business:
P101.473.493.1
Q101.473.493 .001
Commercial General Liability
Richard Yau
11523 Country Spring Court
Cupertino
CA
95014
Santa Clara
Richard Yau
[email protected]
408-309-3970
$1,000,000
$2,000,000
$0
$150,000
January 31, 2023
11523 Country Spring Court
Cupertino
CA
95014
$150,000
© Hiscox Inc. 2010
Project manager (architecture or
engineering)
~·fl
HISCOX
encourage courage• Hiscox Insurance Company Inc.
Your business
Your business's ownership structure Sole Proprietor
------
Is your business operated out of your home? No
Do you currently have an insurance policy in effect for the coverage requested? Yes Project manager (architecture or engineering)
Does your business or any of your subcontractors provide any of the following services or work on any projects involving the following materials or infrastructure (check all that apply}?
• Aerospace engineering
• Amusement rides, pools or playgrounds
• Asbestos, lead, or mold evaluation or abatement
• Bridges, dams, harbors, mines, piers or tunnels
• Condominiums
• Design/build firms
• Emergency response or clean-up of any hazardous waste • Foundation, sheeting or retaining wall design
• Geotechnical / soils engineering
• Home inspections for prospective buyers or lenders
• Hydraulic fracturing, hydrofracturing or tracking
• Laboratory testing
• Land acquisition
• Land surveying , boundary surveying or construction staking • Marine engineering
• Mechanical engineering
• Mining engineering
• Nuclear engineering
• Oil, gas or well engineering
• Petro I chemical engineering
• Structural engineering
• Underground storage tanks or utilities
• None of the above
Does your business or any of your subcontractors directly perform any of the following physical services (check all that apply}?
• Carpentry
• Construction , demolition, or remodeling
• Delivery
• Electrical
• Equipment installation or repair
• Flooring
• General contracting
• Home building
• Lawn or garden maintenance
• Painting
• Plumbing
• Roofing
• Tiling
• Transportation
© Hiscox Inc. 2010
None of the above
None of the above
Page2
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HISCOX
encourage courage• Hiscox Insurance Company Inc.
Your business
• Any other physical maintenance/repair services?
• None of the above
Does your business subcontract any professional services? No Does your business supply, manufacture, or distribute any tangible goods or No products? This does not apply to construction projects your business designs or reviews.
Statements About Your Business
As the individual completing this transaction, you are authorized to purchase and Agree bind this insurance on behalf of the entity applying for coverage.
Your business is not controlled or owned by any other firm, corporation, or entity. Agree For the entire period of time that you have owned and controlled the business, you Agree have not sold, purchased or acquired, discontinued, merged into or consolidated with another business.
Your business has never had any commercial insurance cancelled or rescinded. Agree Business Activities
Your business does not conduct any of the following activities: Agree - Automotive repair or sales
- Food service/restaurant operations
- Medical Services
- Retail Operations
Note: This does not include the activities of your clients in any of these industries.
Claims and Loss History
Based upon your knowledge and the knowledge of your business's current and past partners, officers, directors and employees, during the last five years a third party has never made a claim against your business and you do not know of any reason why someone may make a claim.
© Hiscox Inc. 2010
Agree
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HISCOX
encourage courage • Hiscox Insurance Company Inc.
General Liability
The limits of liability represent the total amount available to pay judgments and settlements for any claims. We are not liable for any amounts that exceed these limits.
If coverage is provided, it shall apply only to occurrences that take place during the policy period.
Judgments, settlements and claims expenses incurred are subject to a deductible amount. The deductible is the amount you must pay before we will make any payments under the policy. Some coverage may not be subject to a deductible, in which case you are not required to make payments before any payments are made under the policy .
Please consult the policy language for details.
If you have knowledge of any circumstance that may lead to a loss or a claim being made against you, coverage will be excluded if such loss occurs or claim is made.
Occurrences that took place prior to the inception of the policy are excluded.
Fraud Warning
For your protection California law requires the following to appear on this form:
Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Policy Cancellation Statement
You have 14 days from inception of your policy/policies to review your documents. If you have no losses or reported claims, you have the right to cancel back to inception for a full refund.
Other General Confirmation Statements
Optional Terrorism Yes
You have declined to purchase optional terrorism coverage.
Optional Business Personal Property Coverage Yes
You have declined to purchase optional business personal property and equipment coverage .
• You can receive your policy documents and important notices, including cancellation and nonrenewal notices, in electronic or paper form.
Agree to receive policy
documents by email
• We will send documents by email or US mail to the address you have provided.
You must notify us if your email or street address changes.
Agree to receive important notices
by email
• For electronic documents, you will need a computer with Internet access and the ability to receive external emails; software such as Adobe Reader® to view and save PDF documents; and a printer to create paper copies. • You can always withdraw your consent to receive documents by email. We will then send documents to you by US mail at no added cost. © Hiscox Inc. 2010 Page 4
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HISCOX
encourage courage• Hiscox Insurance Company Inc.
Other General Confirmation Statements
• To update your email or street address , or to request paper documents , you can contact us at .
The information you provided is accurate and complete and has been used to accept your application and determine the terms and conditions your policy/policies.
I have read the information above and confirm it is correct. I understand that by checking this box and providing the premium payment I agree that I am entering into a binding agreement with Hiscox Insurance Company Inc. © Hiscox Inc. 2010 Page 5
Declaration of Sole Proprietorship
DECLARATION AND ADDENDUM TO ALL CONTRACTS ENTERED INTO OR BID AWARDED TO: ___________ _, hereinafter "Organization"
For the purpose of inducing the City of Cupertino ("City") to enter into any contracts with Organization, or to go forward with any contracts awarded to Organization, I declare as follows:
I am the authorized representative of Organization, an independent contractor for the purposes of workers' compensation and labor laws in the State of California. This Organization will hire no employees for work required for any bid awarded or any contract entered into with the City.
All work required will be performed personally and solely by me.
If the Organization hires employees to perform this contract or any portion thereof, the Organization shall obtain workers' compensation insurance and provide proof of such coverage to the City.
If the Organization hires a subcontractor to perform this contract or any portion thereof, and the subcontractor has employees, then the Organization shall require its subcontractor to obtain workers' compensation insurance coverage. In the alternative, the Organization shall obtain workers' compensation insurance coverage on behalf of the subcontractor's employees.
This document constitutes a declaration by the Organization against its financial interest, relative to any claims that it may assert under the applicable workers' compensation and/or labor laws against the City relating to any bid awarded or contract entered into with this Organization . The Organization shall defend, indemnify and hold harmless the City from any and all liability, claims, demands, causes of action, charges, damages, injuries, fees including attorney fees, costs and expense that may be asserted or established by any person or entity in the event the Organization hires an employee in violation of this addendum.
I agree that this declaration shall constitute an addendum to any bid awarded or any contract entered into with this Organization. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
DATE
AUTHORIZED RESPRESENTA TIVE
Revised, 01 .01.19
State of California
County of Santa Clara
City of Cupertino
Contractor/Consultant Affidavit of No Employees
I, the undersigned, declare as follows:
I am an independent contractor and the owner of _______________ ~ I wish to enter into a services contract with the City of Cupertino . I am fully aware of the provisions of section 3700 of the California Labor Code, which requires every employer to provide Workers' Compensation coverage for employees in accordance with the provisions of that Code. I am also aware that I must provide proof of workers' compensation insurance to the City of Cupertino for any and all employees I may have, pursuant to Section 12 of the City of Cupertino's contract.
I hereby certify that I do not have any employees nor will I have any employees working for me or my business during the term of any service contract with the City of Cupertino. I am not required to have Workers' Compensation insurance .
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Executed on this __ day of----~ 2023, at ________ ~ California.
PRINT NAME
SIGNATURE
Re:,ds_ed 2.05,23 ___ _