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Sep 20 04 12:50p <br />.W , 'k <br />Houston&HarrisPCS <br />9094220841 <br />POLICYHOLDER COPY <br />p.2 <br />STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807 <br />COMPENSATION <br />INSURANCE <br />FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 09-15-2004 <br />CITY OF SANTA ANA <br />M-21 ROSS ANNEX 4TH FL <br />20 CIVIC CENTER PLAZA <br />SANTA ANA CA 92704 <br />GROUP: <br />POLICY NUMBER: 127063e-2003 <br />CERTIFICATE ID: 372 <br />CERTIFICATE EXPIRES: 12-01.2004 <br />12-01-2003/12-01-2004 <br />This is to certify that we have issued a valid Workers Compensation insurance policy in a forth 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 />policy 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 to which it may pertain, the insurance afforded by the policy <br />described herein is subject to all the terms, exclusions, and Conditions, of such policy. <br />gUrHORREO REPRESENTATIVE <br />PRES:DCNT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #1600 - WILLIAM C HARRIS, PRES - EXCLUDED. <br />ENDORSEMENT #1600 - LARVIN B HOUSTON, VP - EXCLUDED. <br />ENDORSEMENT #1600 - PAMELA D HOUSTON, SEC,TRES - EXCLUDED. <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 12-01-1992 IS <br />ATTACHED TO A14D FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />HOUSTON a HARRIS PCS INC <br />21531 BARTON RD <br />GRAND TERRACE CA 92313 <br />sc; <br />D U315-nol <br />SCIr ID]B2E Accept leis cemlcalemly Iyou seealanl walcrrt,aMlwvuatls'OFHCIgL STATE FUND COCl1MENi' RINTEPAGE 10`1 <br />