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<br />29 Dc'' 04 05: lla <br /> <br />Charleen Jones <br /> <br />909,698,5436 <br /> <br />p,2 <br /> <br />POLICYHOLDER COPY <br /> <br />STATE <br /> <br />P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807 <br /> <br />:OMPENSATION <br />N$URANCI! <br />F:U N D CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />IE SUE DATE: 07-22-2004 <br /> <br />GROUP: 000229 <br />POLICY NUMBER: 27195-2004 <br />CERTIFICATE 10: 22 <br />CERTIFICATE EXPIRES; 02-07-2005 <br />02-07-2004/02-07-2005 <br /> <br />C:TY OF SANTA ANA <br />A' 'TN: SHARON HEIT, PURCHAS ING <br />2'} CIVIC CENTER PLAZA-PMB 1986 <br />SCINTA ANA CA 92702 <br /> <br />T '\Is is to certify that we have Issued a valid Worker's Compensation insurance policy in a form approved by the California <br />Ir surance Commissioner to the employer named below for the policy period indicated. <br /> <br />T lis pancy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. <br /> <br />V fa will also give you 30 days advance notice should this policy be cancelled prior to its nonnal expiration. <br />T his 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 requirement, term or condition of any contract or other document with <br />r'3spect to which this certificate of insurance may be issued or may pertain, the insurance afforded by the policies <br />cescrlbed herein is subject to all the lerms. exclusions, and conditions, of such policies. <br /> <br />:~ <br /> <br />} UTHOR\ZEO REPRESENTATIVE <br /> <br />,&~ <br /> <br />c. <br /> <br />&L <br /> <br />PRESIOENT <br /> <br />STANDARD POLICY EXCLUSIONS, <br />EMPLOYEES COVERED UNDER CPL <br />WORKERS COMPENSATION LAW. <br /> <br />INDIVIDUAL EMPLOYERS, HUSBAND AND WIFE EMPLOYERS, <br />INSURANCE AND EMPLOYEES EXCLUDED UNDER CALIFORNIA <br /> <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br /> <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 06-29-2004 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br /> <br />/:f/l~jß7 <br /> <br />EMPlOVER <br /> <br />JONES, EARL DOYLE AND JONES, <br />PACIFIC SYSTEMS ELECTRIC <br />38330 VIA LA PALOMA <br />MURRIETA CA 92563 <br /> <br />CHARLEEN wREY DBA: <br /> <br />SC\F10Z62e: <br /> <br />Açcepl this cor1iftcale only if you S08 II faint watermark Ihs.l reads .OFfICIAL STATE FUND DOCUMENï <br /> <br />~1~~~:O7-22'2004 <br />PAGE I OF1 <br />