CAMBODIAN FAMILY, THE 5 - 2004 - Laserfiche WebLink

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SC CYHOLDER COpy STATE PO BOX 807, SAN FRANCISCO,CA 94142-0807 RECEIVED HAY 2 6 2005 COMPENSATION INS U ~AN C E FUN D CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE, 06-30-2005 GROUP, POLICY NUMBER 1696570-2005 CERTIFICATE ID: 3 CERTIFICATE EXPIRES, 06-30-2006 06-30-2005/06-30-2006 CITY OF SANTA ANA PO BOX 1988 SANTA ANA CA 92702 SC This is to certify that we have issued a valid Work.ers' 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 10 days'advance notice should thiS' policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies listed herein. Notwithstanding any requirement. term, or condition of any contract or other document with respect to which this certificate 01 insurance may be issued or may pertain. the insurance afforded by the policies described herein is subject to all the terms. exclusions and conditions of such policies. ~ /!~c &L- AUTHORIZED REPRESENT A TIVE PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000.00 PER OCCURRENCE. APPROVED AS TO FORM it!i"-V' ~4 , Laura Stitt syedY Assistant City Attorney EMPLOYER LEGAL NAME THE CAMBODIAN FAMILY 1111 WAKEHAM AVE STE E SANTA ANA CA 92705 THE CAMBODIAN FAMILY (REV.3-0J) PRINTED: 05/17/2005 P0409 THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND se" >0".