Laserfiche WebLink
<br />,.~~R~~5 2004 lO:28AM HP LASERJET 3200 <br />- Ø2/~~ _15: 11 STATE COHPENSATlCtI .. 913103702474 <br /> <br />'J <br /> <br />NJ. 779 <br /> <br />p.5 <br />IõI002 <br /> <br />'-./ <br />POLICYHOLDER COpy <br /> <br />i <br />I <br />Ii <br /> <br />STATE P.O, sox 420801. SAN FRANCISCO. CA 94142.0807 <br />CO"'~E"SATIO" <br />IN~U~""'" <br />FUND CERTIFICATE OF WORKERS' COMPENSATION INSuRANCE <br /> <br />I~~UE DATE, 02-03-2004 <br /> <br />GROUP: <br />POLICY NUMBER: 15)~"4-200t <br />CERTIFICATE 10 107 <br />CERTIFICATE EXPIRES' 01-01-iO05 <br />01- 01-2004/01-01-200 5 <br /> <br />CITY OF SAm'/\ AlIA <br />RIS]( tWlA~EMI!N'1' <br />POBOX 1938 II-a <br />SANl'A ANA CA 92'702 <br /> <br />~~:.:. ~m~;:'~ ~:=:;:~.::r:;¡,;~:,=~C'V=n:,=." . form IPPIO'lOd by In. CoJIIcmie <br /> <br />Tnil policy I. not SUÞjec:llo,Cln~lIotlcn by fie Fund ..oep\ upon 30 dlyo advoncewritlen notice 10 !he ""pla¡¡er. <br />We will... gIve y<>o; 30 day"advance I1O!IGelllouid lhIa policy be oancollll<l,priðrtol" narmal..øiroUcn. <br />ThIs ~III 01 .,.."an..ls noun InSiJran<:8 pplloyand dOli nollmend, .._or .lIer'" COVI",ge.lIorQod by \11. <br />poIl"".II8Il<IlIIrlltn. NoIwIthol8ndìng ony ~irlm.rt III"" or conClitlcn 01111' conlred or otIIer dOQlmont IMtn <br />re&p<ld 10 which tills ~II 01 ino...nCII may be illlUOd or me1 pettaln, IIIIInSorance .!Iorded t>r 1110 poIiclo. <br />_,ibed herein I. suÞ~ to 01 1I101òtRl.. ...luoIono. ond ÇM( nlons. alsoch poliol.., <br /> <br />~ <br /> <br />AU_iD..",...""""," <br /> <br />,6~ t. rL. <br /> <br />"""INT <br /> <br />EMPI.OYft'S I.IA!IILtTY LIMIT IH<:LUDntG D!P13NSB C:OSTS, $1,000,000 PD OC:CURRBHCI!, <br /> <br /> <br />EHDDRSiMEN'J' 11600 - BaAIH P DALE, P, S. l' - EXCI.UDED. <br /> <br />iNDORSEMENT H205S ENTITLED CD.TIFICA'I'1! HOLDERS' NOTIC1! En1!CTIVE Ol-01-200t IS <br />Al"I'ACilED TO AND FOJMS A PART OF THIS POLICY. <br /> <br />.1 <br /> <br />oðÎu!a[fr , <br /> <br />""PLOy," <br /> <br />IIYGI2NE tECllllDLDGI1I:S IN1'BaIIArIONAL, I"';' . <br />3625 'DEL lIMO, BLVD sorB 1$0 <br />TORRANe:!: CA 90503 <br /> <br />. ._-~ -<.- -- ,_..... -""....ok" ~... '."to...."", "",ooa.......... <br /> <br />=.'i/.. ....,. <br />-,r, <br />