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<br /> <br />CERTIF.ICATE HOLDER COPY <br /> <br />P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807 <br /> <br />FU N D CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />APRIL 1, 2004 <br /> <br />GROUP: 000046 <br />POLICY NUMBER: 10627-2004 <br />CERTIFICATE ID: 829 <br />CERTIFICATE EXPIRES: 01-01-2005 <br />01-01-2004/01-01-2005 <br /> <br />CITY OF SANTA ANA <br />305 E FOURTH STREET #201 <br />SANTA ANA CA 92701 <br /> <br />RE: VARIOUS STREET CORN~RS, 305 <br />EAST FOURTH STREET, SANTA ANA CA <br /> <br />. . <br /> <br />This is to certify that we have issued a valid Worker's Compensation insl,Jrance policy in a form approved by the C.alifornia <br />Insurance Commissioner to the employer named below for the policy period indIcated. . <br /> <br />This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. <br /> <br />We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. <br /> <br />This certificate of insurance is not an insurance policy and does noì 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 may pertain, the insurance afforded by the policies <br />described herein is subject to all the terms, exclusions, and conditions, of such policies. <br /> <br />~ <br /> <br />,&~ <br /> <br />c. <br /> <br />~ <br /> <br />AUTHORIZED REPRESENTATIVE <br /> <br />PRESIDENT <br /> <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE <br /> <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 01-01-2004 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br /> <br />""'.'ï:. <br /> <br />":":... <br /> <br />,~~L7 J6 <br /> <br />...- ",.10 <br /> <br />~ <br /> <br />EMPLOYER <br /> <br />..,. <br /> <br />R J ALLEN, INC <br />10392 ST¡~FORD AVE <br />GARDEN GROVE CA 92840 <br /> <br />SCIF 10262E <br /> <br />IEPF-UI: 841 <br />