CAMBODIAN FAMILY, THE 5 - 2004 - Laserfiche WebLink

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SC CERTHOLDER COpy STATE P.O. BOX 807, SAN FRANCISCO,CA 94142-0807 COMPENSATION INSURANCE FU N D CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 06-30-2004 GROUP: POLICY NUMBER: 1696570-2004 CERTIFICATE ID: 3 CERTIFICATE EXPIRES: 06-30-2005 06-30-2004/06-30-2005 CITY OF SANTA ANA PO BOX 1988 SANTA ANA CA 92702 SC A - ADO 1- 08''1 - ()<f A- ?JDdI- - 1&1 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 10 days' advance written notice to the employer. We will also give you fO days'advance notice should this policy be cancelled prior to its normal expiration. This certificate ofirisurance is not an insurance policy and does not amend. extend or alter the coverage afforded by the policies listed herein. Notwithstanding any requirememt, term, or condition of any contract or other document with respect to which this certificate ofmsurance may be issued or may pertaln,the insurance afforded by the policies described herein is subject to all the terms, exclusions and conditions of such policies. ~ t\~c &L- AUTHORIZED REPRESENTATIVE PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS.: $1,000,000.00 PER OCCURRENCE. VED AS TO FORM APPRO ' ~ -.-.--- ... . . -_.......-~.. v Laura .:1l,.1 -,. , .. Ctty AtI.Orn(:)' AS:;lstant on ''0- ~1.o~;i).7'O~ F'r-i I "...;<..... ,-,ii"".. n",'" ;];'<'-1 EMPLOYER LEGAL NAME THECAMBOOIAN FAMILY 1111 WAKEHAM AVESTE E SANTA ANA CA 92705 THE CAMBODIAN FAMILY THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND selF 10265 IREV.3-03) PRINTED' 05/17/2004 P040B