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08/04/2004 WED 09:06 FAX 714 +565 4020 CITY OF SANTA ANA <br />CERTHOLDER COPY <br />STATE P.O. BOX 420807. SAN FRANCISCO. CA 94142 -0807 <br />COMPENSATION <br />INSURANCE <br />FUNQ CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 07 -20 -2004 <br />THE DEPOT AT SANTA ANA <br />ATTN CARLYN FULLERTON <br />1000 E. SANTA ANA BLVD STE 109 <br />SANTA ANA CA 92701 <br />16004/005 <br />GROUP: 000046 <br />POLICY NUMBER: 11385 -2004 <br />CERTIFICATE I17: 59 <br />CERTIFICATE EXPIRES: 02 -01 -2005 <br />02 -01- 2004/02 -01 -2005 <br />I <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 />This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. <br />We YAII also give you 30 days advance notice should this policy be cancelled prior to -its normal expiration- <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 mall pertain, the Insurance afforded by the policies <br />described herein is subject to all the terms, exclusions, and conditions, of such policies. <br />AUTHORIZED REPRESENTATIVE <br />A_G.MLL <br />PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 07 -20 -2004 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: <br />THE DEPOT AT SANTA ANA <br />ENDORSEMENT #1600 - STEVEN J RUSSELL, PRESIDENT - EXCLUDED. <br />ENDORSEMENT #1500 - MARCIA L.RUSSELL, SEC,TREAS. - EXCLUDED. <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 02 -01 -2004 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />JAMES H RUSSELL & SON, INC <br />2122 S WRIGHT ST <br />SANTA ANA CA 92705 <br />PRINTED: 07.20.2004 <br />sGF taZ6ZE ACNI)I 0Ne cerUneale only Iryou me a INntwelermant teal rewle'CFFIGAL STATE FUND DOCUMENT- PAGE 1 OF t <br />