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IDAHO STATE INSURANCE FUND
DREW S. FORNEY 1215 W. STATE STREET - PO BOX 83720 - HOISE, IDAHO 83720-0044 PHILIP E. BATT
MANAGER PHONE (208) 334-2370 - (800) 334-2370 GOVERNOR
CERTIFICATE OF INSURANCE
ISSUED T0:
CITY OF MERIDIAN PROJECT: CHERRY LANE GOLF COURSE
33 E IDAHO
MERIDIAN, ID 83642
The State Insurance Fund hereby certifies that the insurance policy hereunder described is in
full force and effect on the date of this certificate and that it remains in full force and
effect until canceled.
NAME(S) OF INSURED: HANSGEORG BORBONUS LANDSCP INC
DBA: CLOVERDALE NURSERY
MAILING ADDRESS OF INSURED: 2528 NO CLOVERDALE RD
BOISE, ID 83713
Policy in force from 10/01/86 12:01 a.m., standard time at the address of the insured shown above
or the job site in Idaho.
Type of Insurance Policy Number Coverage
Workers Compensation 521246 Subject to the terms of the Workers
Occupational Disease Compensation Laws and Occupational
Disease Laws of the State of Idaho.
Employer's Liability Limits:
Bodily injury by Accident - $100,000 each accident
Bodily injury by Disease - $500,000 policy limit
Bodily injury by Disease - $100,000 each employee
The insurance coverage applies to employees of the above-mentioned company working anywhere in
the' state of Idaho and also to any employees living in Idaho but working temporarily in a
neighboring state. In addition to the required coverage, the following elected overage alsc
applies:
AG PURSUITS
This certificate is valid for one year from date of certificate. In the event of cancelation of
said policy, the State Insurance Fund will endeavor to notify the party to whom this certificate
is issued by providing ten (10) days advance notice, but the State Insurance Fund shall not be
liable in any way for failure to give such notice.
Dat at Boise, Idaho on 7/19/96
Robert H. Creighton SIF OD204 U5PAIGE
Underwriting Manager P20360201
SePV 1 ce Coe1g d'Alene I.awistoa Pocatelb Twin Falls Idaho FaNs
2005 hot-wood Parkway 7118 F Street 353 North 4111, Suite 280 B21 N College Rd 525 Park Averwe
LQCat>-QB$ Suite 227 lewiatoa, ID 83501 P.O. Box 2228 Suite 102 Suite 2c
J Statewide Coeur CAlern:, ID 83814 208!799-5050 Pocatello, iD 83208 Twin Falls, ID 83301
2081733-0053 14aho Falla, ID 83402
208ni25-7287
208!789-1513 2081233-8302