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POLICYHOLDER COPY <br />SP <br />P.O. BOX 8192, PLEASANTON, CA 94588 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 07-01-2020 <br />CITY OF SANTA ANA SP <br />20 CIVIC CENTER Pli <br />SANTA ANA CA 92701-4058 <br />GROUP, <br />POLICY NUMBER: 1354526-2020 <br />CERTIFICATE 11 104 <br />CERTIFICATE EXPIRES: 07-01-2021 <br />07-01-2020/07-01-2021 <br />This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the <br />California Insurance Commissioner to the employer named below for the policy period indicated. <br />This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. <br />We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. <br />This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded <br />by the policy iisted herein. Notwithstanding any requirement, term or condition of any contract or other document <br />with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance <br />afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. <br />Authorized Representative President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2019-07-01 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: <br />CITY OF SANTA ANA <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 07-01-2003 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2020-07-01 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: <br />CITY OF SANTA ANA <br />ENDORSEMENT #1651 - SHARON HENNESSEY, MGRMEMBER - EXCLUDED. <br />REVIEWED & APPROVED <br />By RISK MANAC{EM[NT DiViSiON <br />JUL 2 0 2020 <br />EMPLOYER <br />H?'ANC;INI Il. VILLAREAL <br />HENNESSEY & HENNESSEY LLC SP <br />17602 17TH ST STE 102-246 <br />TUSTIN CA 92760 <br />IREv.7-2014j PRINTED : 07 <br />G. <br />Risk Management Divisian <br />41"o'A ° <br />REVIEWED & APEPRC�YV�ED BY. <br />P,. Y+XX 4444 . <br />Risk Management Analyst <br />