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<br /> <br />CERTHOLDER COpy <br /> <br />STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807 <br />COMPENSATION <br />INSURANCE <br /> <br />F=UN D CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />ISSUE DATE, 12-02-2003 <br /> <br />GROUP: 000046 <br />POLICY NUMBER: 12D55-2003 <br />CERTIFICATE 10: 48 <br />CERTIFICATE EXPIRES: 06-01-2004 <br />06 -01-2003/D6-0l-2004 <br /> <br />.1- ;2003-/ tP3 <br />------- "',A - d--DO3 - ;;25..3 <br />CITY OF SANTA ~~ <br />ATTN, KIM PFF.TFFI<R , " \ <br />20 CIV'fC CENTER PLAZA <br />SANTA ANA CA 92701 <br /> <br /> <br />JOB, ALL OPERATfONS <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 Ihe policy period indicated. <br /> <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 normal expiration. <br /> <br />This certificate of insurance is not an insurance policy and does not amend, extend or aller the coverage affDrded by the <br />policies listed herein. Notwithstanding any requirement, term or condition of any contract or other document with <br />respect to which !his certificate of insurance may be issued or may pertain, the insurance afforded by the policies <br />described herein is sUbjècl to all the terms, exdusiOns, and cond~ions, of suchpoiicièS. <br /> <br />~ <br /> <br />,&~ <br /> <br />c. &L- <br /> <br />AUTHORIZED REPRESENTATIVE <br /> <br />PRES/DENT <br /> <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS, $1,000,000 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 />¿..~C>~ , <br />:Ç-\I. <br /> <br /><1r t' ~G 0,>" <br /> <br />L.=~ <br /> <br />O<-c...,- <br /> <br />-'¡" ¡;;........ S ToT E'" é....:s:: ~ <br /> <br />"""'îb <br /> <br />~ <br /> <br />IL. ,~ <br /> <br />'ì'\ð. EO o--.r-- <br /> <br />S' T~\- - c.. ~,~;:- <br /> <br />~~"""-<'I <br /> <br />~,~ <br /> <br />IS <br /> <br />EMPlOYER <br /> <br />APPROVED AS TO FORM <br /> <br />~ c£7___- <br /> <br />-- Laura S,i" ')KeCCIY <br />"",iSlnnt C,'y Allernc'" <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 />SCIF 1O262E <br /> <br />¡;',\-/\:¡i'è!,"..2-20O> <br />PAGE 1 OF' <br /> <br />"""'pi /hi, ".1ifiĊ“.. ""y' "'" ~. """ w...~.. Ih" ,..... "OFFICIAL STATE FUND DOCUMENT" <br />