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~R COPY · STATE F'.O. E~OX 420807, SAN FRANCISCO, CA 94142-0807 COMPENSATION I=UN D CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 08-t4-2003 CITY OP 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 is to certi~;,' that we have issued a valid W,,r~e,)'~ c:r,mpensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy pedod 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· AUTHORtZEO REPRESENTATIVE PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 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 t ORM · ,,,~it~ City Attorney EMPLOYER BOYS AND GIRLS CLUB OF SANTA AMA CORPORATION) 950 HIGHLAND ST SANTA ANA CA 92703 (A NON PROFIT SCIF 10262E Accept this cedifTcate only if ~u see a faint waterrner~ that reads "OFFICIAL STATE FUND DOCUMENT" LTY SP PAGE 1 OF 1