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<br />CERTHOLDER COpy <br /> <br />STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807 <br />COMPENSATION <br />INSURANCE <br /> <br />FUN C 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 /> <br />.1- ;)003-1&3 <br />//-----~- ",A - (7-003 - ,;253 <br />CITY OF SANTA ANA '\~ <br />ATTN: KIM PF"-T"""-" " \ <br />20 ClVÍC 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 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 9ive 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 all thelerms, exclusions, and condnions, of suchpölicies. <br /> <br />~ <br /> <br />~~ C. ()£ <br /> <br />AUTHORIZED REPRESENTATIVE <br /> <br />PRESIDENT <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>'2 , <br />~'iI. <br /> <br />% t' ~GC",," <br /> <br />L.LO.- <br /> <br />0,,---,,--<- <br /> <br />-\'" ~ 'S T"T<õ' G.I .¡::: <br /> <br /> b <br /> <br />~ <br /> <br />"ì"\C\ EO.-..r- <br /> <br />Ie. ,~ <br /> <br />ç T~\.- ~ c... ~ ~ -= <br /> <br />~.:....c,-"'-<:'I <br /> <br />~,~ <br /> <br />APPROVED AS TO FORM <br /> <br />,-- ~ -6----- <br /> <br />Laura S'itt S»lhcl; <br />.\,,15"'nl Cily Allernev <br /> <br />IS <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 />SCIF 10262E <br /> <br />-pi """"'fiœ" ""y""" ~,""'tw,"~~ th,t,.."" 'OFFICIAl. STATE FUND DOCUMENT' <br /> <br />l"'Riili',r/,,12-02-20Œ <br />PAGE 1 0F1 <br />