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<br />08/04/2004 WED 09:06 <br /> <br />FAX 714+565 4020 CITY OF SANTA ANA <br /> <br />!4J 004/005 <br /> <br />CERTHOLDER COPY <br /> <br />STATE <br /> <br />P.O. BOX 420e07. SAN FRANCISCO. CA94142-0e07 <br /> <br />I;O"",,..NSATIQN <br />INSURANCe <br /> <br />FUN D CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />ISSUE PATE: 07-20-2004 <br /> <br />GROUP: 000046 <br />POLICY NUMBER: 11385-:2004 <br />CERTIFICATE ID: S9 <br />CERTIFICATE EXPIRES; 02-01-2005 <br />02-01-2004/02-01-2005 <br /> <br />THE DEPOT AT SANTA ANA <br />ATTN CARLYN FULLERTON <br />1000 E. SANTA ANA BLVD STE 108 <br />SANT~ ~A CA 92701 <br /> <br />) <br /> <br />This is to cenlfy that we have Issued a valid Worker.s Compensation Insurance policy in a form approved by the Califomia <br />Insurance Commissioner to the employer named below for the policy period indicated. <br /> <br />This policy is not subject to cancellaüon by the Fund except upon 30 days advance writien notice to the employer. <br /> <br />We will also gIve you 30 days advance notice should this policy be cancelled priorto'ils normal expiration. <br /> <br />This certlf1cate 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 ms¥ 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 />,ð~ <br /> <br />c. <br /> <br />1)£ <br /> <br />AUTHORIZED REPRESENTATIVE <br /> <br />PRESIDENT <br /> <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br /> <br />ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 07-20-2004 IS <br />ATTACHED TO AND FORMS Ä þA}(.T O~ THIS POLICY. NAME OF ADDIT'!'ONAL INSURED: <br />THE DEPOT AT SANTA ANA <br /> <br />ENDORSEMENT #lS00 - STEVEN J RUSSELL, PRES¡DENT - EXCLUDED. <br />ENDORSEMENT #1600 - MARCIA L.RUSSELL, SEC,TREAS. - EXCLUDED. <br /> <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIV~ O~-01-2004 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br /> <br />I~ <br /> <br />EMPLOYER <br /> <br />JAMES H RUSSELL & SON, INC <br />2122 S WRIGHT ST <br />SANTA ANA CA 9~705 <br /> <br />SClF 1 a~i2¡¡ <br /> <br />ACOIIpllhls celUllCIIle 0IVy II yo¡¡ see s fIIInl ~slernulrl< IIISI fellde "OFFICIAL 5TATE FUND DOCUMENT" <br /> <br />~~~~~: 07.200~OO4 <br />PAGe 1 OF 1 <br />