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SP <br />- L HOLDER COPY <br />STATE P.O. BOX 807, SAN FRANCISCO,CA 94 T42—OBQ7 <br />COMPENSATION <br />y€N Sr UR'A MQE <br />FUN© CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />,ISSUE DATE: 09-04.-2004 dROUP: <br />POLICYNUMBER: 077631IF-2004 <br />',. CERTIFICATE ID:,... 92 <br />CERTIFICAT@ L�,(fEj�iES: 09.;.A1-2005 <br />Osi-01-¢004/0,4�,';tit-2005 <br />CITY OF"SANTA ANA'- SIP <br />ATTN-JOHN'`MALONEY' <br />20 CIVJCENTER PLAZA <br />SANTA ANA to 92702 <br />'This is to cerfify'that we,:hage issued a valid Workers': Compensation insuranc#'Policy in -,A form approved by the <br />California Insurances pCommissfoner to the employer named below for the policy period indiFated, <br />This policytis not %3ubject to cancellation by the Fund except upon 30days' advance written notice to the employer. <br />c We will also giye`you 39 days' advance notice shouid"'thl§ policy.:be ` mIcelled,'prior to its ncirmlal expiration. <br />This certificate ofX m$orAnce-is not an insuraTl'ce perticy and ,does not amepd,':extend, �OY'aI'ter the coverage afforded <br />.:by the policies Ii$tgii herein. Notwithstanding any, requiremoot,, term, or condo 1, of ahy ctsntrapt or, other document <br />• with reSpeCt to which this cerTHjcate of insurance may-=Be`s§'su%j: or may 0,40i :n, the insurance' Sffotded by the <br />policies described herein is subject to all the terms, exclusions and conditions "of s oh, �olicies.. <br />r <br />AUTHORIZE,D REPRESENTATIVE - PRESIDENT' <br />EMPLOYER'S LIABILITY Lfj4IT'INCLUDING DEFENSYE:COSTS'_'-g1,000,000 r <br />' = , _ f Q',, EE 2 OCCURRENCE'. <br />,ENDOR$l MENT, d2065"ENTITLEDCERTIFICATE HOLDERS" NdYZCE•EeEECTIT�E, 09'-01 20QA;iS'ATTACHED-TD AND <br />PORNS,APART OF THIS PbLICY'.' x - <br />a. X- <br />t <br />IV <br />, •Y• <br />n <br />�.r t <br />v a EMPLOYER.,:.. <br />..,'' KErL • NAME <br />�.Sk •Y�' d. <br />Y <br />w., w4GAL AID SOCIETY OF ORANGE LEGAL Aiip SOCIETY OF, ORANGE couNTY= <br />COUNTY ATTN'., JAN,MICHAEL ",(A*ON-PRbFIT CORP.j <br />• 902 1+ MA IN ST <br />'SANTA ANA CA 92701 <br />