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<br />. , . <br /> <br />SP <br /> <br />CERTHOLDER COpy <br /> <br />STATE <br /> <br />COMPENSATION <br />INSURANCE <br />FUND <br /> <br />PO BOX 807, SAN FRANCISCO,CA 94142-0807 <br /> <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />CITY OF SANTA ANA <br />WORKCENTER ATTN: ANABELL YATES <br />1000 E. SANTA ANA BLVD., #200 <br />SANTA ANA CA 92701 <br /> <br />SP <br /> <br />GROUP: 000723 <br />POLICY NUMBER: 0000075-2004 <br />CERTIFICATE 10: 1 <br />CERTIFICATE EXPIRES: 06"01-2005 <br />06-01-2004/06-01-2005 <br /> <br />JOB: ALL OPERATIONS <br /> <br />ISSUE DATE: <br /> <br />06-01-2004 <br /> <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 /> <br />This policy is not subject to cancellation by the Fund except upon 10 day_s' advance written notIce to the employer. <br /> <br />We will also give you 10 days'advance notice should this policy be cancelled prior to its normal expiration. <br /> <br />This certificate of Însurance is not an insurance policy and does not amend; extend or alter the coverage afforded <br />by the P91ièieslisted herei~'f\Jotwithstanding any r~quìn?rTl,ent. term. or condition ~f any contract or other document <br />with respect,:to which this certificate of'insuranqe maybe issued or maypert~¡n.the insurance afforded by the <br />policies described herein IS subject to aU the ter:;ms, exclusions and conditions of such policies. <br /> <br />~ <br /> <br />~~C <br /> <br />&L- <br /> <br />AUTHORIZED REPRESENTATIVE <br /> <br />PRESIDENT <br /> <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: <br /> <br />$1 , 000, 000.00 PER OCCURRENCE. <br /> <br />.ENDDRSEMENT #0015 ENTITLEO AODITIDNAL. INSURED EMPLOYER EFFECTIVE 06-01-2004 IS ATTACHEO TO AND <br />FORMS A PART OF THIS PDLICY. <br />NAME OF ADDITIONAL INSURED: CITY OF SANTA ANA <br /> <br />SP <br /> <br />;""'''ROVED AS TO <br /> <br />"--~ ----- <br />~--' LISA E.--C;TORCK <br /> <br />(~r~~ ~)ttnr . <br /> <br />EMPLOYER <br /> <br />LEGAL NAME <br /> <br />BOYS AND GI RLS CLUB <br />950 HIGHLAND ST <br />SANTA ANA CA 92703 <br /> <br />OF SANTA ANA <br /> <br />BOYS AND GIRI,;S CL.UB OF SANTA ANA <br />(A NON PRoFIT CORPORATION) <br /> <br />THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND SCIF 10265 <br /> <br />(REV.3-03) <br /> <br />PRINTE~: ." 05/17/2004 P040B <br />