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08/04/2004 WED 09 =07 FAX 714 +565 4020 CITY OF SANTA ANA Z005/005
<br />CERTHOLC]ER COPY „
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<br />�, CERTIFICATE',1 "OFD V1[,O�RKERS''I: CQMpEN$ATIQNauJUSURANC�
<br />ISSUE, .DATE F 02- 01-2004 h aXA' ^Sy GROUP- 'i 000046
<br />V'i" "�' ;1POLICY .NUMBER;
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<br />-2004
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<br />=CS02 -01 -205 "rGERTIFICATEr,
<br />02 -0``1 4/10 -01 -2005
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<br />1600`1 S •SANTA RNA. BLVD 300
<br />y� SANTA' "ANA CA .92701,';,',<', ^'''wy;
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<br />Th'ig i8 :to certify, that we, have issued a' valid Workers` Compensation''irisurua�ice „po cy' in"'a '''f'orrri 'approv'ed, by the ;
<br />Californiti Insurance Commission -er to th¢r' employer Hemet# bel'ruw; "!'fir ",a+ie':policy period';,iridicaied,,
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<br />This, "policy is not subject to cancellation' by'the' Fund except upon 30 days, advance WA.&,eih notice to the' employer, ' ,
<br />YVe'will' also give you 20•days advance notice sfaould this policy be canoelled''Jprior to its :norniet' °eacpiraiion: "`rryi
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<br />Thi's „ceriificate,:bf in5ijranGQ,,,15'; rtat;ah ,igsivance policy and' does not'r;,arr�end, expend or alter,,,rths rcpvarags;¢;aff,orded
<br />by,tha•< oliciesi listed'herelk",Notwithstandi4g. any requ(r;ernerm term, or',condition of,ea�anny;conyaoi or'otlier'document
<br />policies spab'scrbed which this,
<br />s subrylect to ill'tFiert6rmrt a clu ons aadr' contlAitfa ri's!nf�5uCltspUQtlartce afforded by th'e'
<br />AUTkoRIZEO rRCPRESENTATIVE 'PRESIDENT'
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<br />EMPLOYJERI-S, lT' pBIL' ITY,` L '•INIT:•'hIQC['�UDING * +AEF,ENSE gCDS 4 1',; 000 ;,000?40,;PER:'OCCLMRENCE +:,
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<br />�ENDORSpMENT '$ dj,XK1 -TLED CER1ar mT HLDER$'„ NOTICE' 9FFFI C
<br />Ol 5 A P1AT OFk THI , POLICY
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