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RTHOLDER COPY <br />SP <br />ATE P.O. BOX 807, SAN FRANCISCO,CA 94142-0807 <br />COMPENSATION' <br />INSURANCE ~ 1_~~~_D.7 ~1 <br />FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE Ili _ ~CJC~3-C7~'-C%/ <br />ISSUE DATE: 12-31-2004 GROUP: 000828 <br />- POLICY NUMBER: 0000318-2004 <br />CERTIFICATE ID: 28 <br />- CERTIFICATE EMPIRES: 12-31-2005 <br />12-3t-2004/12-31-2005 <br />OFf1CE OF THE SANTA ANA CITY ATTORNEY Joe: <br />ATTN MS :fUANITA HERNANDEZ <br />20 CIVIC CENTER PLAZA - <br />SANTA ANA CA 92701 <br />This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the <br />California Insurance Commissioner tc tho omploycr named below for the pofcy 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'aduance 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, extendor alter the coverage afforded <br />by the polices Ustetl harem: Notwithstanding any requirement, term, or condition of any contract or other document. <br />wnh respect to which this deftificate of insurance may be-issued or may pertain, the insurance afforded by the <br />policies described herein is subject to all the terms, exclusions and conditions of such policies. <br />AUTHORIZED REPRESENTATIVE PRESIDENT <br />,EMPLOYER'S 1IA5ILITY LIMIT INCLUDING DEFENSE COSTS: 57,000;000.00 PER OCCURRENCE. <br />`- ENDORSEMENT X2085 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE"72-31-2004 'IS ATTACHEDTO AND <br />'FORMS A PART OF TNIS POLICY. - <br />EMPLOYER <br />wev <br />LYCOM DATA SYSTEMS, INO--- <br />1055 ELIZABETH DR' <br />RICHMOND KY 40475'.. <br />LEGAL NAME <br />CYCONDATA SYS7EM5, INC <br />oo~~iror~. 11/ 17/2004 <br />