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<br />CERTHOLDER COpy <br /> <br />STATE P.O. BOX 420807, SAN FRANCISCO. CA94142-0807 <br /> <br />COMPENSATION <br />'NSURANce <br /> <br />F=U N C CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />ISSUE DATE: 12-02-2003 <br /> <br />GROUP: 000046 <br />POLICY NUMBER: 12055-2003 <br />CERTIFICATE ID: 48 <br />CERTIFICATE EXPIRES: 06-01-2004 <br />06-01-2003/06 -01-2004 <br /> <br /> <br />,1- .2003-/ &3 <br />--------- "'A - ifoo3 - ;253 <br />CITY OF SANTA ~~ <br />ATTN: KIM P"F.T""F.~ . \ '\ <br />20 ClVîë CENTER PLAZA <br />SANTA ANA CA 92701 <br /> <br />JOB: ALL OPERATIONS <br /> <br />This is to certify that we have issued a valid Worker's Compensation insurance policy in a fonn 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 /> <br />We will also give you 30 days advance notice should this policy be cancelled prior to its nonnal 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, tenn 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 tenns. exclusions, and conditions, of such policies. <br /> <br />~ <br /> <br />,&~ C <br /> <br />()£ <br /> <br />AUTHOR"ED REPRESENT A TlVE <br /> <br />PRESODENT <br /> <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <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 />?~C>~ , <br />-:Ç'i::L <br /> <br />% I" ~G""><C <br /> <br />""-C>.-- <br /> <br />O"--'C-~ <br /> <br />-\"'- ~ S ToT'" G -I .;= <br /> <br /> b <br /> <br />i='-<- <br /> <br />\1:\ E: o-J"o <br /> <br />iL. \~ <br /> <br />ÇT\\-~ c:..~.~" <br />~ <br /> <br />~.:...c-... '<-<. <br />I <br />~,~ <br /> <br />APPROVED AS TO FORM <br /> <br />- 6~£-- <br /> <br />'\SSiWll1t Cily AllCrl1CV <br /> <br />1<;' <br /> <br />EMPLOYER <br /> <br />ORANGE COUNTY CONSERVATION CORP. <br />CORP.) <br />700 N VALLEY ST STE B <br />ANAHEIM CA 92801 <br /> <br />(A NON PROFIT <br /> <br />SCOF 1O262E <br /> <br />-~"", o:enruœ.. ""'. yo" -. ..., ~- 'h",eo', 'OFFOCIAL STATE FUND DOCUMENT' <br /> <br />W'\¡'iii'~b'12"2-20" <br />PAGE 1 0", <br />