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POLICYHOLDER COPY <br />P.O. BOX 8192, PLEASANTON, CA 94588 <br />GROUP: <br />POLICY NUMBEFt, 9017252-2020 <br />CERTIFICATE 10: 90 <br />CERTIFICATE EXPIRES: 07-01-2021 <br />07-01-2020/07-01-2021 <br />CITY OF SANTA ANA RISK MANAGEMENT DIVISI1 <br />20 CIVIC CENTER PLZ <br />SANTA ANA CA 92701-4068 <br />This Is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the <br />California Insurance Commosionar to pro employer named below for the policy period Indicated. <br />This policy is not subject to cancellation by the Fund except upon So days advance written notice to the employer. <br />We vvili also give you 30days advance notice should this policy be cancelled prior to Its normal expiration. <br />The, certificate of Insurance is not an Insurance policy mid does not amend, extend or after 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 insursooe <br />afforded by the poI14 described herein is subject 114 all the terms, exclusions, and conditions, of Such policy, <br />Authorized Representative President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDINO DEFENSE COSTS: $1,000,000 PER OCCURRENCE, <br />1 11171 <br />s. <br />ENDORSEMENT 01901 - OOHN DAVID REAVER, MEIRMOR - EXOLUDEO <br />ENDORSEMENT #1951 - MICHAEL JAMES BEAVER, MORMBIR - EXCLUDED. <br />ENDORSEMENT #1951 - VERONIQUE REAVER, MGRMBR - EXCLUDED. <br />ENDORSEMENT #1951 - PHILIPPA JANE REAVER, MIGIRMISA - EXCLUDED. <br />ADLERHORST INTERNATIONAL LLC SP <br />3951 VERNON AVE <br />JURUPA VALLEY CA 92509 <br />-M <br />(FWV,7-2c14) <br />REVIEWED & APPROVE) BY. <br />PRINTED 0 <br />