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a <br />Jun-28-04 07:49A <br />STATE PO. BOX 807, SAN FRANCISCO,CA 94142-0807 <br />COMPENSATION <br />IN+.+SU. RAN C6. <br />FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />'SSUE'DATE: 04-01,2004. GROUP: <br />-- POLICY NUM9ER, <br />CERTIFICATE !D a <br />CERTIFICATE EXPIRES. 04 -e t <br />04-01 2004104 ..,! 7-CS <br />STATE, STATE OF CALIFORNIA Sp JOB: At-- OPT O,rt <br />DEPARTMENT OF COMMUNITY SERVICE 'b DEVELOPMENT <br />700 NORTH 10TH STREET RM° 258 <br />SACRAMENTO CA 55814-0338 <br />This is,to cortifv thatwe. have issued a valid Workers': Compensation insurance :policy in a ors <br />California Insurance. COmm,ssoner to the OMPIOYer named below for the policy periodInd cated. <br />: This policy ,s not subject to caneollation by. the Fund except upon 1D days' advance Written nit r = _. <br />V✓e Will .also Rive you t0 days' advance notice should this policy be cancelled prior. to itF. n0. •^a , <br />This certificate of rnsuranta Is not an nisufance Policy and does not amend,. extend or alter the <br />by me paiicitis listed here,n.. Notwahstanding' any, requirement,'. term, or corditinp of any contra. ;fA_,. <br />with respect to which trui certificate of jnsurarAce,_mSybe issued'Ot may'Pertain the-instiranc a- Ie <br />Policies described herein >s subject to all -the Terms.' exclusions and conditions nf., such pa!ices. <br />.AUT.,iCRIZE'D RLPRF$ENTti T'IVE - PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DE1rENSE'COSTS: $1,000,000,00 PER OCCURRENCE. <br />EMPLOYER - LEGA.L. NAME <br />VIETNAMESE COMMUNITY OF ORANGE VIETNAMESE COMMUNIT4 <br />COUNTY, INC to NON-PROFIT CORP : <br />T613. W 1S[ ST <br />SANTA ANA (A 92703 t <br />sav:.a-oa; ,,�.. <br />�.03i <br />•I�tF3.7ti'T.i:Ttft'1:'r/1'1lra_ _ <br />