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w <br />�2©D2-)D535 <br />HOLDER COPY <br />STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807 <br />COMPENSATION <br />INSURANCE <br />FU N DICERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />MARCH 17, 2003 GROUP: <br />POLICY NUMBER: 682268-2003 <br />CERTIFICATE ID: 28 <br />CERTIFICATE EXPIRES: 01-01-2004 <br />01-01-2003/01-01-2004 <br />SANTA ANA COMMUNITY DEVELOPMENT AGENCY <br />20 CIVIC CENTER PLAZA <br />SANTA ANA CA 92702 <br />This is to certify that we have issued a valid Worker's Compensation insurance policy in a form approved by the California <br />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 30 days advance written notice to the employer. <br />We will also give you 30 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 by the <br />policies listed herein. Notwithstanding any requirement, term or condition of any contract or other document with <br />respect to which this certificate of insurance may be issued or may pertain, the insurance afforded by the policies <br />described herein is subject to all the terms, exclusions, and conditions, of such policies. <br />AUTHORIZED REPRESENTATIVE <br />A(�, c. &&� <br />PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 01-01-2003 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />ORANGE COAST INTERFAITH SHELTER (A NON-PROFIT CORP.) <br />1963 WALLACE AVE APT A <br />COSTA MESA CA 92627 <br />SCIF 10262E <br />fEPF-UI: GT 1 <br />