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POLICYHOLDER COPY SIP <br />P.O. BOX 8192, PLEASANTON, CA 94588 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 09-01-2021 GROUP: <br />POLICY NUMBER: 9023428-2021 <br />CERTIFICATE 10: 48 <br />CERTIFICATE EXPIRES: 09-01-2022 <br />09-01-2021/00-01-2022 <br />CITY OF SANTA ANA CONN. DEVELOPMENT AGENCY <br />20 CIVIC CENTER PLZ <br />SANTA ANA CA 92701-4058 <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 80 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. Notwithstandin 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 b/y�the <br />ipolicy <br />dedescribed herein is subject to all the terms, exclusions, and conditions,. of. such policy. <br />ks 1 <br />Authorised Represantahve President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT N200E ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 09-01-2012 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />PEOPLE FOR IRVINE COMMUNITY HEALTH A SP <br />NON-PROFIT CORP. OBA: 2-1-1 ORANGE COUNTY <br />1505 E 17TH ST STE 108 <br />SANTA ANA CA 92705 <br />OREM-20141 <br />a ,. Rh4J.4mgrnwdiY�htm <br />;isIi91tMD 6JVYao Or, <br />f ? '7ari �iewcm <br />FhkManaaemau Otti'al /fide <br />PRINTED : 0 - <br />