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POLICYHOLDER COPY <br />No <br />P.O. BOX 8192, PLEASANTON, CA 94588 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 05-27-2020 GROUP: <br />POLICY NUMBER: 9133408-2020 <br />CERTIFICATE 10; 22 <br />CERTIFICATE EXPIRES. 05-27-2021 <br />05-27-2020/05-27-2021 <br />CITY OF SANTA ANA Sp <br />20 CIVIC CENTER PLZ <br />SANTA ANA CA 82701-4058 <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 requfremant, term or condition of any contract or other document <br />with respect to which this certificate of insurance may he issued or to which it may pertain, the insurance <br />afforded by the policy <br />/ddo'scribed herein is subject to all the forms, exclusions, and conditions, of such policy. <br />Authorited Representativ, President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS., $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2020-05-27 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY, NAME OF ADDITIONAL INSURED: <br />CITY OF SANTA ANA <br />ENDORSEMENT N2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 05-27-2020 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY, <br />ENDORSEMENT N1651 - SANTIAGO RODRIGUEZ PRESIDENT - EXCLUDED. <br />ENDORSEMENT N1651 - CYNTHIA RODRIGUEZ SEC,TRES - EXCLUDED, <br />REVIEWED & APPROVED <br />By Risk MANAD(whir DivisiON <br />L 0'2 <br />EMPLOYER FRA GAVE . .I.AREAL <br />AMERICA TRUCK DRIVING SCHOOL, INC, Sp <br />2210 N MAIN ST STE 8 <br />SANTA ANA CA 92706 <br />Risk ManagenantDivicimt <br />RtmwEQ &pAptPt,Rovm By:cat <br />PRINTED 05- <br />Lowal Risk Management Anal#at <br />