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POLICYHOLDER COPY <br />P.O. BOX 8192, PLEASANTON, CA 94588 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 01-22-2019 <br />CITY OF SANTA ANA, PWA, WRD - BRIAN IGE <br />220 S DAISY AVE <br />SANTA ANA CA 92703-4334 <br />SP <br />GROUP: <br />POLICY NUMBER: 1258757-2018 <br />CERTIFICATE ID: 47 <br />CERTIFICATE EXPIRES: 07-01-2019 <br />07-01-2018/07-01-2019 <br />This is to certify that we have issued a valid Workers' Compensationinsurance 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 />byith the policy to which this listed herein. Notwithstanding any requirement, term or condition of any contract or other document <br />respect certificate finsurance e <br />in, the insurance <br />afforded by the herein is subject toab <br />all the termsueds exclusir to ons, ich �a daconditions, of such policy. <br />Authorized Representative /V I <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: Prsi ent and <br />CEO <br />00 PER OCCURRENCE. v/ <br />ENDORSEMENT #2085 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 07-01-1994 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />GONG ENTERPRISES, INC <br />7755 CENTER AVE STE 1100 <br />HUNTINGTON BEACH CA 92947 <br />(REV.7-2014) <br />SP <br />irb, <br />IP11,SGj <br />PRINTED : 01-22-2019 <br />SP <br />