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- . .. . CERTHOLDER COPY STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807 COMPENSATION INSURANCE FU N C CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE, 10-13-2004 GROUP: 000560 POLICY NUMBER: 364-2004 CERTIFICATE ID: 19 CERTIFICATE EXPIRES: 10-01-2005 10-01-2004/10-01-2005 CITY OF SANTA ANA CLERK OF THE CITY COUNCIL 20 CIVIC CENTER PLAZA (M-30) SANTA ANA CA 92704 This is to certify that we have issued a valid Worker's 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 policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. ~ ,&~ I' - . ~ AUTHORIZED REPRESENTATIVE PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS, $1,000,000 PER OCCURRENCE. ,r".---,., ; .. ,-} '. ~I ... 1\ If ,:1 .... => => .= ~.__.. . .--'-' -' ,.- -' ":'1._7, ,:.:A~->j." = C"'> - co » -P. .ç: ...s::: EMPLOYER CARD METER SYSTEMS INC 1104 NORTH ANITA TUCSON AZ 85705 SCIF 10262E [TB,SJ) PRINTED: 10-13-2004 PAGE 1 OF1 Accept this certificate only if you see a faint watermark that reads "OFFICIAL STATE FUND DOCUMENT"