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CERTHOLDER COPY <br />STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807 <br />COMPENSATION <br />I N S U R A N C E <br />FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 06-17-2004 GROUP: 000626 <br />POLICY NUMBER: 31s-2003 <br />CERTIFICATE ID: zs <br />CERTIFICATE EXPIRES: 12-31-2004 <br />12-31-2003/12-31-2004 <br />OFFICE OF THE SANTA ANA CITY ATTORNEY <br />ATTN MS JUANITA HERNANDEZ <br />20 CIVIC CENTER PLAZA <br />SANTA ANA CA 92701 <br />This is to certify that we have issued a valid Worker's Compensation insurance policy in a form approved by the California <br />Insurance Commissioner to the employer named below for the policy period indicated. <br />This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. <br />We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. <br />This certificate of insurance is not an insurance policy and does not 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 />AUTHORIZED REPRESENTATIVE <br />~D~ ~ . ~ <br />PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #1600 - CLIFFORD DON MC GREGOR, PRES - EXCLUDED. <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 12-31-2001 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />~,~. <br />EMPLOYER <br />CYCOM DATA SYSTEMS, INC <br />1055 ELIZABETH DR. <br />RICHMOND KY 40475 <br />INR,SPj <br />PRINTED: 06-17-2004 <br />SCIF 10262E Accept this certificate only if you see a faint watermark that reads "OFFICIAL STATE FUND DOCUMENT" PAGE 1 OF 1 <br />