CAMBODIAN FAMILY, THE 3 - 2004 - Laserfiche WebLink

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SC CERTHOLDER COpy STATE po. BOX 807, SAN FRANCISCO,CA 94142-0807 COMPENSATION INSURANCE FUN D CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 06-30-2004 GROUP: POLICY NUMBER: 1696570-2004 CERTIFICATE 10: 3 CERTIFICATE EXPIRES: 06-30-2005 06-30-2004/06-30-2005 CITY OF SANTA ANA PO BOX 1988 SANTA ANA CA 92702 SC A - :A.oot.f-ot'1-o9 A - J..o04 - [G/l This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 10 days' advance written notice to the employer. We will also give you 10 days' advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend. extend or alter the coverage afforded by the policies listed herein.. Notwithstanding any requirf3ment. term, or condition of any contract or other document with respect to which this certificate of insurance may bei~sued or may pertain, the insurance afforded by the policies described herein is subject to all the terms. exclusions and conditions of such policies. ~ A~t! &L- AUTHORIZED REPRESENTATIVE PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUOING DEFENSE COSTS: $1,000,000.00 PER OCCURRENCE. TO FORM APPROVED AS ~--- .. c.--- -'-- v Launl;'Hi::'~~ ", . .Clty AtlUrnC) ASSIstant. . Oij 1'0. I.,i!:r:.',-.~ ')"'1" ()L'! F'1" "1: /~? i ~--'(;; f"., _ ~", i "v' " ... ... EMPLOYER LEGAL NAME THECAMBOOrAN FAMILY 1111 WAKEHAM AVE STE E SANTA ANA CA 92705 THE CAMBODIAN FAMILY THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND selF 10265 (REV 3-03) PRINTED' 05/17/2004 P040B