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a o03 - 0~'7 <br />f1- ao°3 - 07~-010 <br />CERTHOLDER COPY ~ _ o'YJU3- ~ S.3 <br />STATE P•O. BOX 420807, SAN FRANCISCO, CA 94142-0807 <br />COMPSN SATION <br />I N S U R A N C B <br />PUN D CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 08-14-2003 GROUP: 000723 <br />POLICY NUMBER: 7s-zoD3 <br />CERTIFICATE ID: z <br />CERTIFICATE EXPIRES: 05-o1-zoos <br />06-O1-2003/06-O1-2004 <br />CITY 09 SANTA ANA <br />COMMUNITX DEVELOPMENT AGENCY <br />PO BOX 1988 M-25 <br />SANTA ANA CA 92702 <br />This is tc-certify ihEt ~;;e ha:'e issued a va!Id Wnraar~ C^mpensation insurance policy in a form approved by the California <br />Insurance Commissioner to the employer named below for the policy pedod indir;ated. <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 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 />~~~ <br />AUTHORIZED REPRESENTATIVE <br /> <br />PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 08-14-2003 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: <br />CITY OF SANTA ANA <br />AY}'ROVEll AS ~O t (;I:1V1 <br />;, ilr,l Shccdy <br />-~ ,,:rv City Attorney <br />EMPLOYER <br />190Y8'JiYilfGIRLS CLb$ OF SANTA ANA (A NON PROFIT <br />CORPORATION) <br />950 HIGHLAND ST <br />SANTA ANA CA 92703 <br />ILTV,SPI <br />PRINTE ~ OB-142003 <br />SCIF 10262E Accept iM1ia ceNfiwte only if you seesfainl watermera tM1el reatls "OFFICIAL STgTE FUND DOCUMENT' PAGE 1 OO~F~1~w®-~y~ <br />