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C~[~OLDER COPY STATE P.o. BOX 420807, SAN F~NOISCO, CA 94142-0807 FUN O CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 08-14-2003 CITY OF SANTA ANA COMMUNITY DEVELOPMENT AGENCY PO BOX 1988 M-25 SANTA ANA CA 92702 GROUP: 000723 POLICY NUMBER: 75-2003 CERTIFICATE iD: 2 CERTIFICATE EXPIRES: 06-01-2004 06-01-2003/06-01-2004 This ia to certify thet we h~v~ issued a valid W¢,r~.,',~ c,r, mpensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer. We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or may pertain, the insurance afforded by the policies described herein is subject to all the terms, exclusions, and conditions, of such policies. AUTHORIZEO REPRESENTATIVE PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $t,000,000 PER OCCURRENCE. ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 08-14-2003 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF SANTA ANA APPROVED AS '10 tORM ·.,~y,, City Attorney EMPLOYER BOYS AND GIRLS CLDB OF SA/qTA ANA CORPORATION) 950 ~IGHLAND ST SANTA ANA CA 92703 (A NON PROFIT $ClF I0262E Accept this certificate only if ~ou see a faint watermar~ that reads "OFFICIAL STATE FUND DOCUMENT"