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POLICYHOLDER COPY <br />P.D. BOX 8192, PLEASANTON, CA 94588 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 01-14-2020 <br />CITY OF SANTA ANA, ATTN: RISK MANAGEMENT SP <br />20 CIVIC CENTER PLZ FL 4 <br />SANTA ANA CA 92701-4058 <br />GROUP: <br />POLICY NUMBER: 0702781-2019 <br />CERTIFICATE ID: 107 <br />CERTIFICATE EXPIRES: 08-12-2020 <br />08-12-2019/08-12-2020 <br />THIS CERTIFICATE SUPERSEDES AND CORRECTS <br />CERTIFICATE # 105 DATED 01-14-2020 <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 listed 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 <br />described herein is subject to all the terms, <br />/exclusions, and conditions, of such policy. <br />Authorised Reprosentafive President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2020-01-14 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: <br />CITY OF SANTA ANA. ATTN: RISK MANAGEMENT <br />ENDORSEMENT #20SS ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 08-12-2011 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2020-01-14 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: <br />CITY OF SANTA ANA. ATTN: RISK MANAGEMENT <br />ENDORSEMENT #1651 - NANCY K BOHL P,S,T - EXCLUDED. <br />EMPLOYER <br />NANCY K BOHL INC SP <br />1881 BUS CTR OR STE 11 <br />SAN BERNADINO CA S2408 <br />[P1X,H01 <br />SP <br />(REV.I-2014) PRINTED : 01-14-2020 <br />�al�l� <br />