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STATE P.O BOX 807, SAN FRANCISCO.CA 94 14` -GS'
<br />CO"PrNSATtON
<br />lt4 SUR A NCE v -47 DO-2 -I D-5-5q
<br />PUN'D -,;-'RTIFICATE OF WORKERS' COMPENSATION INSURANCE
<br />J E pft at: r.lF COMMUN ! TY cl- RVICE 6
<br />NOR7-i lC:7H �FPEET RA 258
<br />o 0 j
<br />F C A 7 04 C 1 2004
<br />04-61-2062, ld -0 ! -20104
<br />SP jOZ: ALL OPERATION&
<br />GEVELbPMEf!T
<br />This iv, r v ,ici. ssued 'A,cri.c r- Cnrnu,n 1 7 , ation in
<br />414 Cner it; l-, �mplcyar nanlE,6 below for the po,c, po,10(4
<br />ZnCiFUl;�.1 by Inp. F1,nd e"(,e,;); :.P,r, lod... Cc wvizten Lh,
<br />nrllce sh4iid
<br />.r or td its 'icu"ZI ,,atm�
<br />c .sn0T,an ylsur*,ic6 policy and 0ws , not,amend,
<br />to the cOv0saga afforced �1_,tW.e3 'crfl1p gAa,prjgUineneP�,re-or c0rJIUPI0 any t, ohle: d0cpntV-An re,ecvt,cn th,'Wl'fear4. 4rinurMCL rnty km Assued.0'- lnuv perto;n*he ts;.t.jm.cc al•ordeq of the
<br />I :lub,ject to afft6 *'ertll-,'EXcfyzions'bno concjitjorjs of tq,,h pi,,,,
<br />S.
<br />PRESIDENT
<br />EMPLOYER'S, LIABILI-FY 1.10T INCLUDING
<br />NCLUDING [)E NS CCOSTt:
<br />t 1 000 i 0100 :60: PER OCCURREN6,r
<br />FORNI
<br />Ali'()v hll AS 1v
<br />S,jccdy
<br />C ity Ati,,)rncV
<br />LEGAL NAME
<br />Vz--TNAMEE C-O'VYWNITY CF ORANGE
<br />UUNTY, VIETNAgESE COMMUNITY OF ORANGE coui
<br />16 15 q i S- s—, fA NON-PROrIT CORP
<br />SPNTA ANA,
<br />
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