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04/23/2004 16:49 FAI 5302734702 ANY_GALLOWAYOACORDIA.COM Cbn(11 <br />CERTHOLDER COPY <br />STATE P•O- BOX 420807, SAN FRANCISCO, CA 94142-0807 <br />coMpem"710N <br />IN9u NwNcE <br />F V N D CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 04-23-2004 GROUP: <br />POLICY NUMBER: 177876E-2;4 <br />CERTIRCATE IO: 3 <br />CERTIFICATE EXPIRES: 03-01-2CC5 <br />03-25-2004/03-01-2005 <br />SANTA ANA:-CO=4UNITY.' DEVELOPMENT <br />AGENCY <... <br />P.O. BOX 1988 <br />SANTA ANA CA.92702 ....:...... <br />This is to oeniy that we have Issued a valid Worker's Compensation insurance policy in a form approved by the California <br />Insurance Commissioner to the employer named below for the policy period indicated. <br />This policy is not.subjem.to cancellation,by the. Fund except upon 10 days advance writer). ratite to the employer. <br />We will also gale you 10 days advance notice *mid this polkry be car"lled;priorto Its normal e _.. ... xplration. <br />This certificate of insurance is not an insurance policy and does not amend, eMend or after the coverage afforded by the <br />Policies listed herein. Notwithstanding any requirement,, term or condition ofF.any contract or other document with <br />respect to which this certificate of insurance may be issued or may pertatrl„the'insurance afforded by the policies <br />described herein is subjedto all the terms, exclusions; and.conditions,of such policies. <br />�� ,� - <br />AUTHOPo7PveEPnESSWATNE. ... .PFESOENr <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000, 000 PER OCCUP=EN^_E. <br />EMPLOYER <br />ORASiGE COS,,-NTY BAR FOUNDATION <br />PO BOX 184" .. <br />IRVINE CA 92713 <br />SC& 1� Amvq pVacer9lcew eMy it you tee n mlm wtamxk Ihnt felts �DFGIpAI STATE PUNv OOCUMENi' <br />PB41 EO', 04 20 <br />PAGE I OF I <br />