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<br />. ' <br /> <br />SC <br /> <br />. <br /> <br />fHOLDER COpy <br /> <br />STATE <br />COMPENSATION <br />INSURANCE <br />F=UNO <br /> <br />PO, BOX 807, SAN FRANCISCQ,CA 94142-0807 <br /> <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />ISSUE DATE: 07-01-2005 <br /> <br />GROUP: <br />POLICY NUMBER: 0643808-2005 <br />CERTIFICATE ID: 69 <br />CERTIFICAtE E)(PlflES: 07-01-2006 <br />07-01-2005/07-01-2006 <br /> <br />city OF SART~ ANA <br />COBG PROGRAM <br />P .0. BO X 1988 <br />SANTA ANA CA 9270) <br /> <br />SC <br /> <br />ThiS is to certify tha~ 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 /> <br />'This policy is not subject to cancellation by the Fund except upon 30 days' advance written notice tethe employer. <br /> <br />We will also give you 30 days' ,advance notice should this pOlicy be cancelled prior to its normal expiration. <br /> <br />This certificate of insurance is notaninsurance policy and does not amend. extend ,Or alter the coverage afforded <br />by the policiE;!s hsteci herein. ,NotwithstandiIl9,.any requirement, term, or condition ". of any contractor, other ,document <br />with respect towhkh thiS certificate of inSl,Jrancemaybe issued or may pertain, tne insurance afforded by the <br />policies described herein is sub ject to all', the terms,exclusiol"'os and conditions of,' such policies. <br /> <br />~ <br /> <br />Jj~ c; <br /> <br />~ <br /> <br />AUTHORIZED AEPRESENTATIVE PRESIDENT <br /> <br />EMPLOYER'S LIABILITY LIMIt INCLUDING DEFENSE COSTS: $1 ;000.000.00 PER OCCURRENCE. <br /> <br />ENQORSEMENT#2065 ENTIT~ED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 07-01-2005 IS ATTACHED TO AND <br />FORMS A PART OF THIS POLICY. <br /> <br />A?PROVED AS TO FORM <br /> <br />~~~e4;f? <br />Laura Stitt Shee <br />Assistant City Att6rney <br /> <br />EMPLOYER <br /> <br />LEGAL NAME <br /> <br />MEXICAN AMERICAN OPPORTUNITY FOUN. <br />CLAUDIA GUTIERREZ~RUFINO <br />401 N GARFIELD AVE <br />MONTE BELLO CA 90640 <br /> <br />MEXICAN AMERICAN OPPORTUNITY FOUNDATION <br />(A NON-PROFIT CORP.) <br /> <br />(AEV.3-031 <br /> <br />PRINTED: 06/17/2005 P0408 <br /> <br />THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND self 10265 <br />