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f <br />SP <br />CERTHOLDER COPY <br />STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br />COMPENSATION <br />IN S1JRA N CE <br />FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 07-26-2005 GROUP: <br />POLICY NUMBER: 1354937-2005 <br />CERTIFICATE ID: 38 <br />CERTIFICATE EXPIRES: 04-01-2006 <br />04-01-2005/04-01-2006 <br />CITY OF SANTA ANA <br />COMMUNITY DEVELOPMENT <br />20 CIVIC CENTER PLAZA <br />SANTA ANA CA 92702 <br />SP <br />This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the <br />California Insurance Commissioner to the employer named below for the policy period indicated. <br />This policy is not subject to cancellation by the Fund except upon30 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 <br />by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document <br />with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance <br />afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. <br />AUTHORIZED REPRESENTATIVE <br />PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT N2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 04-01-2003 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />APPROVED AS TO Fo ""' <br />She Y <br />A5 Istalu City Attorney <br />EMPLOYER <br />ORANGE COUNTY ASSOCIATION FOR MENTAL HEALTH <br />822 W TOWN AND COUNTRY RD <br />ORANGE CA 92868 <br />[AKS,CNI <br />PRINTED : 07-26-2005 <br />(REV.2-05) <br />