NANCY K. BOHL, INC., DBA: THE COUNSELING TEAM INTERNATIONAL

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POLICYHOLDER COPY SP P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 08-12-2020 CITY OF SANTA ANA, ATTN: RISK MANAGEMENT SP 20 CIVIC CENTER PLZ FL 4 SANTA ANA CA 92701-4058 GROUP POLICY NUMBER: 0702781-2020 CERTIFICATE ID: 107 CERTIFICATE EXPIRES: 08-12-2021 08-12-2020/08-12-2021 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy /described 7,herein is subject to all the terms, exclusions, and conditions, of such policy. Authorized Representative/ President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE, ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2020-08-12 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF SANTA ANA. ATTN: RISK MANAGEMENT ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 08-12-2011 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION .EFFECTIVE 08-12-2011 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF SANTA ANA, ATTN: RISK MANAGEMENT ENDORSEMENT #1651 - NANCY K BOHL P,S,T - EXCLUDED. EMPLOYER NANCY K BOHL INC 1881 BUS CTR OR STE 11 SAN BERNADINO CA S2408 SP PRINTED : Risk Mrxnagnnent Divielan REVIEWED & APPROVED BY: f � R. V: l - Risk Management Analyst IRE V.7- 20'14)