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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />P N 04 99 07 <br />(Ed. 7-17) <br />POLICYHOLDER NOTICE <br />NOTICE OF CANCELLATION TO CERTIFICATE HOLDER <br />Dear Policyholder: <br />The following provision is being added to your policy effective 0611012021 through 0410912022: <br />In the event that we, the Insurer, cancel this policy for any reason, including non-payment of premium, we will <br />endeavor to send notification of such cancellation to the said certificate holder using the method(s) indicated <br />below: <br />Certificate Holder: CITY OF SANTA ANA <br />Mailing Address: 200 CIVIC CENTER PLAZA 4TH FF, SANTA ANA, CA 92701 <br />Email Address: Not Provided <br />Method of Notice: Mail <br />Notice of cancellation is being provided only to the certificate holder at the address and/or email address listed <br />above. Statutory requirements will determine the number of advance days notice provided for cancellation. If <br />notice is mailed, it will be sent via regular, first-class mail to the address listed above. <br />Notice of cancellation to the certificate holder is being provided for informational purposes only. Failure to provide <br />such notice to the certificate holder will not amend or extend the date the cancellation becomes effective, nor will <br />it negate cancellation of the policy. Failure to send notice shall impose no liability of any kind upon the Company <br />or its agents or representatives. <br />Notice Effective: 06/10/2021 <br />Insured: 4Leaf, Inc. <br />Insurance Company: Redwood Fire and Casualty Ins Cc <br />PN 04 99 07 <br />(Ed. 7-17) <br />Policy NO.: FOWC216539 <br />Policy Period: 04/09/2021-04/09/2022 <br />Countersigned by �RAMmW adDM8ian REVIEWED & APPROVED BY.- <br />3 z <br />Risk Management Analyst <br />