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<br />APPENDIX D <br />(Concluded) <br /> <br />Sample Insurance Forms <br /> <br />Sample Workers' ComD Form <br /> <br />STATE <br />COMPENSATION <br />INSURANCE <br />FUND <br /> <br />P.O. BOX 420807. SAN FRANCISCO. CA 94142-0807 <br /> <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />NOVEMBER 5, 1997 <br /> <br />626-97 UNIT 0000116 <br />POLICY NUMBER: <br />CERTIFICATE EXPIRES: 12 - 31 - 9 a <br /> <br />I <br />CITY OF SANTA ANA <br />INFORMATION SERVICES M-12 ATTN LYNDA KELLY <br />POBOX 1988 <br />SANTA ANA CA 92702 JOB: VERIFICATION OF INSURANCE <br /> <br />L <br /> <br />This is to certify that we have issued a valid Workers' Compensation Insurance policy in a form approved by the California <br />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 ten days' advance written notice to the employer. <br /> <br />We will also give you TEN days' advance notice Should this policy be cancelled prior to its normal expiration. <br /> <br />This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the <br />poliCies listed herein. Notwithstanding any requirem~nt,. term, or condition of any contract or other document with <br />respect to which this certificate of insurance may be issued or may pertain, the insurance afforded by the policies <br />described herein. is subject to all the terms,exclusions and conditions of such policies. <br /> <br />?7~~~ <br /> <br />AUTHORIZED REPRESENTATIVE <br /> <br />K~ <br /> <br />PRESIDENT <br /> <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS:~l,OOO,OOO PER OCCURRENCE <br /> <br />EMPLOYER <br /> <br />I <br />APR CONSULTING INC <br />22632 GOLDEN SPRINGS STE <br />DIAMOND BAR C~ 91765 <br /> <br />380 <br /> <br />L <br /> <br />._.. <br /> <br />.. <br /> <br />. :. <br /> <br />'0 <br /> <br />Page 34 of 35 <br />