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POLICYHOLDER COPY SP P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 10-22-2021 GROUP: POLICY NUMBER: 9282964-2021 CERTIFICATE ID: 84 CERTIFICATE EXPIRES: 10-22-2022 10-22-2021/10-22-2022 CITY OF SANTA ANA SP 20 CIVIC CENTER PLZ 10-22-2020 SANTA ANA CA 92701-4058 HO This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer. We will also give you 10days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. �ili3".`.vc�r L..//4, �ZGr�// .ca..�i•-,^ ,>Cjf-een-u�� Authorized Representative/ President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT N0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2021-08-23 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF SANTA ANA ENDORSEMENT H1951 - CASTRO,JOE, MGR-MEMBR - EXCLUDED. ENDORSEMENT N1951 - PETERSON,MATTHEW, MGR-MEMBR - EXCLUDED. ENDORSEMENT #1951 - ANNIGONI,JOSEPH, MGR-MEMBR - EXCLUDED. EMPLOYER BRIGHTLIFE DESIGNS, LLC SP 16351 GOTHARD ST STE C HUNTINGTON BEACH CA 92647 [P17,H0] (REv.7-2D14) PRINTED : 11-30-2021