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POLICYHOLDER COPY <br />STATE ! <br />P,O. BOX 8192, PLEASANTON, CA 94588 SP <br />FUND! <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 12-01-2018 <br />GROUP: <br />POLICY NUMBER: 1110288-2018 <br />CERTIFICATE 10: 10 <br />CERTIFICATE EXPIRES: 12-01_2019 <br />12-01-2018/12-01-2019 <br />CITY OF SANTA ANA <br />PARKS RECREATION AND COMMUNITY SERVICES SP <br />20 CIVIC CENTER PLZ <br />SANTA ANA CA 92701-4088 <br />This is to certify that we have issued a valid Workers' COmpensatio� insurance policy in a form approved by the <br />California Insurance Commissioner to the employer named below for the Polic <br />y Y period intllcatetl. <br />This policy ie 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 "mice should this policy be cancelled prior to its normal expiration. <br />Tnis certificate of insurance is not an insurance by the policy listed herein. Nwvwjhstnidin@ any requirement, term or condition of an <br />y contract 01 with respect 10 Which this certificate of insurance omay ba ssuey and does tl or to whichot amend it ma or alter the coverage afforded <br />afforded by the policy described herein is subject to all the terms, exclusions, and li pertain, <br />a ouch policy her ant <br />terms, <br />/. a Y Pertain, the insurance <br />Authorized Representative <br />UNLESS INDICATED OTHERWISE BY ENDORSEMENT, President and CEO <br />THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EEMPLOYER R THIS DORCA HUSBAND BANDSgNDEWI ELEMPLOYER; <br />EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING <br />CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES E%CINSURLUDED UNDER POLICY <br />CALIALSO WORKERS' <br />COMPENSATION LAW. <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $ "000,000 PER OCCURRENCE. <br />ENDORSEMENT N0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2017-12-01 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY <br />CITY OF SANTA ANA . NAME OF ADDITIONAL INSURED; <br />ENDORSEMENT N206S ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 12-01-1998 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />IKENBERRY, DENNIS AND IKENBERRY, .IUDY 229 S OLIVE AVE SP <br />RIALTO CA 92376 <br />(REV-7 2014) <br />[PlM,HOJ <br />PRINTED : 08-09-2019 <br />