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<br /> <br />CERTHOLOER 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: 12055-2003 <br />CERTIFICATE 10: 48 <br />CERTIFICATE EXPIRES: 06-01-2004 <br />06-01-2003/06 -01-2004 <br /> <br />"1- ),,003-/&3 <br />~----._- "",A - ;),,003 - .;253 <br />CITY OF SANTA ~~ <br />ATTN, KIM PF"TFF"~ . \ \ <br />20 ClVÍë 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 form approved by the California <br />Insurance Commissioner to the employer named below for the 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 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 subject to alilhe terms, exclusions, and conditions,of such. pOlicies. <br /> <br />~ <br /> <br />,&~ C. 1)£ <br /> <br />AUTHORIZED REPRESENT."VE <br /> <br />PRESIDENT <br /> <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS, $1,000,000 PER OCCURRENCE. <br /> <br />ENDORSEMENT #15B6 - 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>'2 ( <br />~'iI. <br /> <br />% \" ~GC>'>" <br /> <br />0<-,,--<- <br /> <br />-\oc- ¡;;;,.- os ToT;; c:. ~ .;= <br /> <br />¿=~ <br /> <br /> b <br /> <br />~ <br /> <br />iL,~ <br /> <br />"'" E:....r-- <br /> <br /><;':.~....- ~~~~ <br /> <br />~~"""-<;'J <br />~c~ <br /> <br />,-> <br /> <br />EMPLOYER <br /> <br />APPROVED AS TO FORM <br /> <br />--~ d<7._. <br /> <br />Laura Stite ~"cI)' <br />.\ssiswnf City MccraeY <br /> <br />ORANGE COUNTY CONSERVATION CORP. <br />CORP.) <br />7DO N VALLEY ST STE B <br />ANAHEIM CA 92801 <br /> <br />(A NON PROFIT <br /> <br />SCIF 10262E <br /> <br />w,¡,?ii'~'12.02'200' <br />PAGE 1 OF 1 <br /> <br />Aooept ""œrufiœ" only """ ~. f"",w.I.~~ thot re"" 'OFFICIAl STATE FUND DOCUMENT' <br />