Laserfiche WebLink
POLICYHOLDER COPY <br />P.O. BOX 8192, PLEASANTON, CA 94588 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 09-23-2021 GROUP: <br />POLICY NUMBER: 9262964-2020 <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 10 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 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 <br />dbby� the <br />policy <br />yydedescribed 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 N0015 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 #2572 ENTITLED BLANKET WAIVER OF SUBROGATION EFFECTIVE <br />2020-10-22 IS ATTACHED TO AND FORMS A PART OF THIS POLICY <br />ENDORSEMENT N1951 - CASTRO,JOE MGR-MEMBR - EXCLUDED. <br />ENDORSEMENT #1951 - PETERSON,MATTHEW MGR-MEMBR - EXCLUDED. <br />® ENDORSEMENT #1951 - ANNIGONI.JOSEPH MGR-MEMBR - EXCLUDED. <br />EMPLOYER <br />BRIGHTLIFE DESIGNS, LLC SP <br />16351 GOTHARD ST STE C <br />HUNTINGTON BEACH CA 92647 <br />(REV.7-2014) PRINTED : Ot <br />SP <br />Riak M¢nag�.mmf DiNnion <br />REMEWEo 3 APPROVED BY: C <br />R¢k klanagement Analyst <br />