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/� CERTHOLDER COPY SP <br />STATE E P.O. BOX 807; SAN FRANCISCl 94142 -0807 <br />COMPENSATION <br />INSURANCE <br />- <br />FUN D CERTIFICATE OF WORKERS' COMPENSATION 'INSURANCE <br />ISSUE DATE: 06 -01 -2004 GROUP: 000723 <br />POLICY NUMBER: 0000075 -2004 <br />CERTIFICATE D: 1 <br />CERTIFICATE EXPIRES: 06 -01 -2005 <br />06 -01- 2004/05 -01 -2005 <br />CITY OF SANTA ANA SP JOB; ALL OPERATIONS <br />WORKCENTER ATTN: ANABELL YATES <br />1000 E. SANTA ANA BLVD., #200 <br />SANTA ANA CA 92701 <br />This is to certify that we have issued a valid Workers' Compensation insurance policy m a form approved by the <br />California 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 10 days' advance written notice to the employer. <br />We will also give you 10 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 <br />by the policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document <br />with respect to which this certificate of insurance may 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 />& c- ML <br />AUTHORIZED REPRESENTATIVE PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS.: $1,000,000.00 PER OCCURRENCE. <br />ENDORSEMENT #0015 ENTITLED ADDITIONAL,. INSURED EMPLOYER :EFFECTIVE 06 -01 -2004: IS ATTACHED TO AND <br />+. FORMS A PART OF THIS POLICY. <br />NAME OF ADDITIONAL INSURED: CITY OF SANTA ANA SP <br />AS TO <br />`___- — <br />LISA F, S'OHCY. <br />ssislant i:ItY Af *or;' " . <br />EMPLOYER <br />- -LEGAL NAME <br />BOYS AND GIRLS CLUB OF SANTA ANA BOYS AND GIRLS CLUB of SANTA ANA <br />950 HIGHLAND ST i (A NON PROFIT: CORPORATION);. <br />SANTA ANA CA 92703 <br />(REV.3 -03) <br />PRINTED: 05/17/2004 P0408 <br />