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<br /> <br />CERTHOLOER COpy <br /> <br />STATE P.O. BOX 420807. SAN FRANCISCO. CA94142-0807 <br />COMPENSATION <br />INSURANCE <br /> <br />FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />ISSUE DATE: 12-D2-2003 <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 /> <br />CITY OF SANTA ANA '\ <br />ATTN: KIM PFF.r""F," ' <br />20 cntrc CENTER PLAZA <br />SANTA ANA CA 92701 <br /> <br />,1- :2.003-/ (P3 <br />.'A - ð-DO3 - .;253 <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 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 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 sobjeclto all the terms, exclusions, and cond~ions,of such policies. <br /> <br />~ <br /> <br />,&~ C. ~ <br /> <br />AUTHOR"ED REPRESENT A T1VE <br /> <br />PRES'DENT <br /> <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS. $1, OOD, 000 PER OCCURRENCE. <br /> <br />ENDORSEMENT #1586 - VOLUNTEER COVERED. <br /> <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 06-01-2003 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br /> <br />¿"~D'2 ( <br />+="-i:r.. <br /> <br /><1;- \" ~GC>""- <br /> <br />0<...-<--<-- <br /> <br />-<.... ¡;;,..--. S ToT ¡z- C. ~ .¡::: <br /> <br />L..C:o- <br /> <br /> b <br /> <br />~ <br /> <br />"'" E:"""'" <br /> <br />\::.,~ <br /> <br />ç ':.':"0.- - c.. ~ ~" <br /> <br />~.;.,.."....,<--<.., <br />~,~ <br /> <br />IS <br /> <br />EMPLOYER <br /> <br />APPROVED AS TO FORM <br /> <br />.~~1_.-- <br /> <br />Laura Sli,' ~"cI/ <br />'\S$iswot City AtlcrncY <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 />1"'R,\?!if/',"'02-'OO3 <br />PAGE 1 OF1 <br /> <br />Aoœp11hi. """œ.. ndy '",""" 0 ""'Iwo""",~ thol""", "OFFICIAl STATE FUND DOCUMENT" <br />