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POLICYHOLDER COPY P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 10-22-2023 GROUP: POLICY NUMBER: 9262964-2023 CERTIFICATE I❑: 175 CERTIFICATE EXPIRES: 10-22-2024 10-22-2023/10-22-2024 CITY OF SANTA ANA SC JOB:CITY OF SANTA ANA 20 CIVIC CENTER PLZ 20 CIVIC CENTER PLZ SANTA ANA SANTA ANA CA 92701-4058 CA 92701 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 10 days 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. Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2022-10-22 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF SANTA ANA ENDORSEMENT #1951 - MATTHEW PETERSON, MGR-MEMBR - EXCLUDED. ENDORSEMENT #1951 - JOSEPH ANNIGONI, MGR-MEMBR - EXCLUDED. ENDORSEMENT #1951 - JOE CASTRO, MGR-MEMBR - EXCLUDED. EMPLOYER BRIGHTLIFE DESIGNS, LLC 15351 GOTHARD ST STE C HUNTINGTON BEACH CA 92647 Sc SC a ,,o,,,�.:,. RIeltMiuwgetnaltD[v{elrnt REmFwED & APPRovED 8Y: c' i'I'l+� ilGty� Risk Management Specialist (REV.7-2014) PRINTED : 10-24-2023