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<br />CERTHOlOER COpy <br /> <br />STATE P.O. BOX420807,SAN FRANCISCO, CA94142-O807 <br />COMPENSATION <br />INSURANCE <br /> <br />FUN D CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />ISSUE DATE, 12-02-2D03 <br /> <br />GROUP: 000046 <br />POLICY NUMBER: 12055-2003 <br />CERTIFICATE 10: 48 <br />CERTIFICATE EXPIRES: 06-01-20D4 <br />06 -01- 2003 / 06 - 01- 2004 <br /> <br /> <br />,1- ),,003-1&3 <br />--------- "'A - ð-.oo3 - ,;253 <br />i~~, O~I~~;~T~~ <br /> <br />20 CIV'fë CENTER PLAZA <br />SANTA ANA CA 92701 <br /> <br />JOB, ALL OPERATIONS <br /> <br />This is to certify that we have issued a valid Worke"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 /> <br />This policy iB not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. <br /> <br />We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. <br /> <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 sUbjèct to all the terms, exclusiOns, and conditions, of suchpoliciès. <br /> <br />~ <br /> <br />,&~ c. &L <br /> <br />AUTHORIZED REPRESENTATIVE <br /> <br />PRESIDENT <br /> <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS, $1, ODD, 000 PER OCCURRENCE. <br /> <br />ENDORSEMENT #1586 - VOLUNTEER COVERED. <br /> <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 06-01-2003 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br /> <br />¿"~D"2 I <br />+="iI. <br /> <br />% 1" ~GC",," <br /> <br />L-c>- <br /> <br />oC-C-<- <br /> <br />-\'" ~ STOT"" c.S ~ <br /> <br /> b <br /> <br />~ <br /> <br />~E:"""" <br /> <br />iL,~ <br /> <br />'>,\ \- - c.. ~~" <br />~ <br /> <br />~.:....c,-""<-<'I <br /> <br />~c~ <br /> <br />APPROVED AS TO FORM <br /> <br />,s <br /> <br />EMPLOYER <br /> <br />ORANGE COUNTY CONSERVATION CORP. <br />CORP. ) <br />700 N VALLEY ST STE B <br />ANAHEIM CA 92BD1 <br /> <br />(A NON PROFIT <br /> <br /> <br />SC'F 1O262E <br /> <br />-~"';, œotif='" "'" . YO' ~ 0"""_,""""", ""'reo', "OFFICiAl STA'" FUND OOCUMENT" <br /> <br />~1f;in12-C2-20œ <br />PAGE 1 OF' <br />