O.C. CONSERVATION CORPS 4 - Laserfiche WebLink

Home Browse Search

CERTHOLDER COPY STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807 COMPENSATION INSURANCE FUN D CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 12-02-2003 GROUP: 000046 !,z POLICY NUMBER: 12055-2003 `,•_ av(-�� 3 CERTIFICATE ID: 4e CERTIFICATE EXPIRES: 06-01-2004 06-01-2003/06-01-2004 CITY OF SANTA ANA ATTN: KIM 20 CIXffC CENTER PLAZA SANTA ANA CA 92701 JOB: ALL OPERATIONS This is to certify that we have issued a valid Worker's Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. We will also give you.30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or after the coverage afforded by the policies listed herein_ Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or may pertain, the insurance afforded by the policies described herein is subject to all the terms, exclusions, and conditions, of such policies. AUTHORIZED REPRESENTATNE A(�,c.A4- PRESIOEE EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #1586 - VOLUNTEER COVERED. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 06-01-2003 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. G> 50-;� r T 4 EMPLOYER APPROVED AS TO FORM ORANGE COUNTY CONSERVATION CORP. (A NON PROFIT CORP.) ., . _-.__.__.. 700 N VALLEY ST STE B Laura Stw $ eedq ANAHEIM CA 92801 asistant City AuorneY SCIF 10262E Accept Nis scats s* H you see a Haim asteneark Nat reads -OFFICIAL STATE FUND DDCUMENr' A1WN PRIEE :12-02-2003 PAGE 1 OF 1