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w SP . THOLDER COPY STATE P.O. BOX 807, SAN FRANCISCO,CA 94142-0807 COMPENSATION INSURANCE FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 04-01-2005 GROUP: POLICY NUMBER: 0682897-2005 CERTIFICATE ID: 101 CERTIFICATE EXPIRES: 04-01-2006 04-01-2005/04-01-2006 CITY OF SANTA ANASP JOB: COMMUNITY DEVELOPMENT AGENCY PO BOX 1988 SANTA ANA CA 92702 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 30 days' advance written notice to the employer. We will also give you 30 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 requirement, term, or condition of any contract or other document with respect to which this certificate of insurance may be issued or may pertain, the insurance afforded by the policies described herein is subject to all the terms, exclusions and conditions of such policies. X" AUTHORIZED REPRESENTATIVE PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS:. $1,000,000.00 PER OCCURRENCE. ENDORSEMENT -#0015ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 04-01-2005 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF SANTA ANA SP ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 04-01-2005 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. APPROVED As TO FORM Laura Stiit'Sheedy Assistant City Attorney , EMPLOYER LEGAL NAME DAYLE MC INTOSH CENTER FOR THE DISABLED, INC 13272 GARDEN GROVE BLVD GARDEN GROVE CA 92843 DAYLE MC INTOSH CENTER FOR THE DISABLED INC. #2 (A NON-PROFIT CORP.) (REV.3-03) PRINTED: 03/17/2005