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POLICYHOLDER COPY <br />SP <br />P.O. BOX 8192, PLEASANTON, CA 94588 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 08-23-2021 GROUP: <br />POLICY NUMBER: 9282984-2020 <br />CERTIFICATE ID: 84 <br />CERTIFICATE EXPIRES: 10-22-2021 <br />10-22-2020/10-22-2021 <br />CITY OF SANTA ANA SP <br />20 CIVIC CENTER PLZ 10-22-2020 <br />SANTA ANA CA 92701-4058 HO <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 10 days advance written notice to the employer <br />We will also give you 10days 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 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 insurance <br />afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. <br />Authorized Representative/ President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2021-08-23 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: <br />CITY OF SANTA ANA <br />ENDORSEMENT H2572 ENTITLED BLANKET WAIVER OF SUBROGATION EFFECTIVE <br />2020-10-22 IS ATTACHED TO AND FORMS A PART OF THIS POLICY <br />ENDORSEMENT N1851 - CASTRO,JOE MGR-MEMBR - EXCLUDED. <br />ENDORSEMENT X1951 - PETERSON,MATTHEW MGR-MEMBR - EXCLUDED. <br />ENDORSEMENT N1851 - ANNIGONI,JOSEPH MGR-MEMBR - EXCLUDED. <br />EMPLOYER <br />BRIGHTLIFE DESIGNS, LLC SP <br />16351 GOTHARD ST STE C <br />HUNTINGTON BEACH CA 92647 ,, R1ek M1l°"'grnuaiDtwel°" <br /><Y Y�°.. REVIEWED&ryAP'PR0VW8y.' <br />I 8?bL0Yk4 a R V cif AFAS <br />(REV.7-20141 <br />PRINTED 0NEW <br />Risle 4lmiagement Analyst <br />