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POLICYHOLDER COPY SC <br /> STATE <br /> COMPENSATION P.O. BOX 8192, PLEASANTON, CA 94588 <br /> INSURANCE <br /> FUND <br /> CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> ISSUE DATE: 10-22-2024 GROUP: <br /> POLICY NUMBER: 9262964-2024 <br /> CERTIFICATE ID: 175 <br /> CERTIFICATE EXPIRES: 10-22-2025 <br /> 10-22-2024/10-22-2025 <br /> CITY OF SANTA ANA SC JOB:CITY OF SANTA ANA <br /> 20 CIVIC CENTER PLZ <br /> 20 CIVIC CENTER PLZ SANTA ANA <br /> SANTA ANA CA 92701-4058 CA 92701 <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 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 2023-10-22 IS <br /> ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: <br /> CITY OF SANTA ANA <br /> ENDORSEMENT #1951 - JOE CASTRO, MGRMBR - EXCLUDED. <br /> ENDORSEMENT #1951 - MATTHEW PETERSON, MGRMBR - EXCLUDED. <br /> ENDORSEMENT #1951 - JOSEPH ANNIGONI, MGRMBR - EXCLUDED. <br /> ENDORSEMENT #1951 - JOSEPH ANNIGONI, MGRMBR - EXCLUDED. <br /> EMPLOYER <br /> N oR.BRIGHTLIFE DESIGNS, LLC Riak Marugnent I)Msbn <br /> SC e^ <br /> t. REVIEWED F.APPROVED BY.16351 GOTHARD ST STE C a <br /> HUNTINGTON BEACH CA 92647 ''' *zc�t' <br /> Risk Klanagentent Specialist <br /> (REVJ-2014) <br /> PRINTED 09-17-2024 <br />