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~. n ~:.~ i : ~' ' j: K_ r3 t 9 iV.-.""T"Yy +' ~,Xa'~~,aT`~~.L~~s ~--" -.'$P <br />-. `* ., Jµ s 1+, ~ r ~E ~OLDEf2 'COPY `~,~ ~vs,.. ~'( .~.' <br />/ ~.. ,. ~ <br />STMTE ~ ~ P.O. BOX 807; SAN FRANCISCO,CA 9442 0807 ~ .~ ~ ZODZ 04-3 <br />COMPENSATION <br />1"' U N ~ CERTIFICATE OF ;.WORKERS` COMPENSATION'`1NSURANCE , <br />ISSUE DATE: 04-01-2003 ~ GROUP: 000488 ~. <br />POLICY NUMBER:-0000168-2003 <br />""' ~ CERTIFICATE.ID: -"~-_78 ""~ ~" <br />CERTIFICATE EXPIRES: 04-01-2004 <br />`. 04-Oi-2003/04-01-2004 ,. <br />CLTY OF SANTA ANA SP <br />' ATTN 'LUGY,F'LORES; <br />;' Po eox `i988 <br />,, <br />SANTA ANA CA 92r-]02 ; <br />~ Y 4 <br />... l'~ <br />This is to certify that we have issued a valid Workers" Compensation insurance policy in aform approvedby the . <br />Calrfornia 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 ~p days' advance written notice to the employer. <br />We will also give :you ap days ~~adva ~e notice should this policy be cancelled prior. to its Formal expiraUOa <br />i a <br />This cectifiPate of ,insurance is not ari in9uri3nce policy .and .does not arriendfextend%or. alter .the goJerage afforded <br />by the :policies rlisled herein:~NOtvvith`standing any requirement; ;term, orcogditior~'of~anycontnct'"or-^other 'document <br />with resp'ecC~to which this'certficate of, insurance maq"be ;issued or may tpertam, ;"thi: insurance afforded by'the ~ * '- <br />policies d"escribeC herein is subject to all tfie teems; "ekcfusi6ns'.'and conditidns gf,`such policies... {, ;;~. ' <br />P 1 }f <br />AUTHORIZED AEPRESENTATIVE :`S PRESIDENT '", ~~ <br />' rs, <br />'. EMPLOYER'S,,LIABILITY LIMIT INCLUDING DEFENSE COSTS;t $1 000;000.00 PER"OCCURRENCE. <br />n .. ;. '.t <br />F <br />~t <br />,. tiD~~o ~ z,: ~1~ ~rc ~'~~: <br />~~. <br />. , ,..; <br />Lauce Sheedy <br />Dzputy City ~ttnrncy` <br />EMPLOYER <br />...LEGAL NAME ~ '. <br />'ANAHEIM INTERFAITH SHELTER,- ANAHEIM °INTERPAITH SHELTER, ?~INc <br />+INC ~ (A NON; PROFZT. PUBLIC BENEFIT) <br />i' 626 N PAULINE ST' - _: <br />' ANAHEIM CA 92805 ~ ~ '~ <br />. - ;; PRINTED 03= 77 2003 ,P0408 __ <br />