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GENTIFM7ATE HOLMft COPY <br />STATE P.D. aox 42M?, SAN FRMGIBCO, GA' 94u2-=-f <br />� ...■NSA M <br />I IisY RAM � , <br />FUND CERTII°ICATE OF WORKERS' CflNSASION INSURANCE <br />APRIL s, 2'00 4 papRt�ouyATE ukvy <br />.CEFtTY4 �s�issl coos <br />OE MPIWE EXPIRES: os-of-2oo4 <br />CITY OF SAM, :.. <br />ATTMI aet>kl:ludr'iz: .. . <br />20 CIVIC CmeT='7Lxan <br />ARMSA ANA CA Ra701 CITY OF BAtI'1'A AMA -ALL CITYM211d <br />PA04tCIe, <br />ITo is 10 co <br />lwrplwe me vm ma laa qlI v w WNW* Cmpaer tlr polnMtl011 Mnrm oaft Ina knn e4Pro"d by toOefimle <br />q�patod• ; <br />TNM MW Is not OUNSO D 6er01WM bY'ft Fun# an=$ upoR,,O MKMdQwN" wlMw►m Ww to ft emp%W. <br />we M 100e.0" OY .30 dOA sdvana MOM "MO* poft.bA 0000" alarm Me normal explro0ne. <br />TNeoeNAo of b�, _k_ _IRd en meluaa ._May and dow.nt# ward a mkw Ow coverage atbrdad by the <br />aalase Road now, o ay ro�.Rl° elk bwwama�wtl 6 my ammW er ather doa,mem �, <br />de b d h m a th .1 I w wrol may an�nndd wnd94" vr;, thop lane. a anbrded by tl� 4oNoae <br />,III'I� e��AL <br />NRUOR20REPOMOOSM "mow." <br />EMPLDYM 9 LIMkLITY LIMIT INCLMIM'DZFSNSS COflTB: j1,000,000 PSA OCCURRENC$ <br />RtIp"JA IEMT i$045 tlai'PITLiD C$RTI9TCAT6 $OLO)!A9' MOTiCt! EFPBCTIVB 09-01-7003 I6 <br />ATTACHED TO AMD'FORM A PART OS TRIG POLICY. , <br />hr <br />L):IO'HT01T• OB10VP, .IHC..DDA: L$EO>ti'1'OH CGNSULTI90,: INC. <br />17791 CDMAN BTZ:.100 <br />iRYi>aA CA 97451;, ,..... <br />Emil, g IEPWI:611 <br />80'd SS:6 v00Z 9 .add S19S-ZV9-vTZ:xPA '7d G& 9N3 - H S AIIO <br />