Laserfiche WebLink
SP <br />` CERTHOLDER COPY <br />STATE P.O. BOX 807; SAN FRANCISCQCA 94142 -0807 <br />COMPENSATION <br />INSURANCE f <br />FUND CERTIFICATE OF WORKERS' COMPENSATION 'INSURANCE <br />ISSUE DATE: 06 -01 -2004 GROUP: 000723 <br />POLICY NUMBER: 0000075 -2004 <br />CERTIFICATE ID: 1 <br />CERTIFICATE EXPIRES: 06 -01 -2005 <br />06 -01- 2004/06 -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 in 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 10days' 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 contractor other document . <br />with respect to which this certificate of insurance may be 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. 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 />V�E�I/JAS <br />TC) a <br />_ — LISA E. <br />ssistant City .4ttorr <br />EMPLOYER - -LEGAL NAME <br />BOYS AND GIRLS CLUB OF SANTA ANA BOYS AND GIRLS CLUB OF SANTA ANA <br />9 50 HIGHLAND ST (A NON PROFITI CORPORATION): <br />SANTA ANA CA 92703 <br />PRINTED: 05/17/2004 P0408 <br />IREV.3 -031 <br />