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r• <br />CERTHOLDER COPY <br />STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142 -0807 <br />COMPENSATION <br />I N S U R A N C E <br />FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 07 -14 -2004 <br />CITY OF SANTA ANA WIC \ YZ <br />ATTN ANNABEL BATES <br />PO BOX 1988 -M -73 <br />SANTA ANA CA 92702 <br />GROUP <br />POLICY NUMBER: 1738022 -2004 <br />CERTIFICATE ID: 3 <br />CERTIFICATE EXPIRES: 04 -01 -2005 <br />04 -01- 2004/04 -01 -2005 <br />This is to certify that we have issued a valid Worker's Compensation insurance policy in a form approved by the California <br />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 30 days advance written notice to the employer. <br />We will also give you 30 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 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 may pertain, the insurance afforded by the policies <br />described herein is subject to all the terms, exclusions, and conditions, of such policies. <br />AUTHORIZED REPRESENTATIVE <br />PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT 42065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 04 -01 -2003 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />CALIFORNIA HISPANIC COMMISSION ON ALCOHOL AND DRUG <br />ABUSE, INC. A NON- PROFIT CORPORATION <br />2101 CAPITOL AVE <br />SACRAMENTO CA 95816 <br />SCIF 10262E Accept this certificate only if you see a faint watermark Nat read$ "OFFICIAL STATE FUND DOCUMENT" <br />IKLS, NF' <br />PRINTED: 07-14 -2004 <br />PAGE i OF 1 <br />