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<br />11/12/213134 <br /> <br />12:133 <br /> <br />NO. 6013 GlB02 <br /> <br />CERTHOLDER COPY <br /> <br />STATE P.O. BOX 420807, SAN FRAIIICISCQ, CA~4142-0807 <br />(:OM~.N~nCN <br />INSyflltANr;.. <br /> <br />FU N D CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />ISSUE DATE. 11-12-2004 <br /> <br />GROUP: <br />POLICY NUMBER: U15an,2004 <br />CERTIFICATE 10: 15 <br />CERTIFICATE EXPIRES: 04-01-2005 <br />"4-01-2004/04-01-2005 <br /> <br />, I <br /> <br /> <br />crn OF aAI'lTA AHA <br />l'1lIILJ:C 11I01UG AGIlNCY <br />PO BOX J.!i88 <br />SAII'l'A AKA CA 9 2 7 02 <br />, <br /> <br />JOB: AT'l'!!l JOJ; ~A.RCO <br /> <br />I <br />.' <br /> <br />Thi; is 10 certify that Wi have ilmIGd ; valid Wolle;r', Coml)tn..tien in$ur"'''''@ pcll")ll" a Ill"" app_ by tho Cllrrfomlo <br />Insurance Commilllonerto tM empl0}'9' nMle\l ~iIO\Alforlh. pelloy p",lod Indleatlld, <br /> <br />TIlls polley 10 not 9UIljll<ll tD canCOlI"'ticn bylhD I'und __pt upcn 30 day_ advsnce writlsn notice 10 the employ,,,. <br /> <br />WQ Will also gll/e you 30 days advan"" noti"" ~hould tIli~ policy boI canCilllod prior to it.& normal @XJliratlon. <br /> <br />1l'lis C8ltifiCBl.. 01 insurance I. not an Insul1lnoo policy.n<l ~on not ""'en~, extend or eltet tile coverage alfiJrd.d by the <br />polO)' netetl herein. Notwllll.tan<ling any requlremont. l$m1 0< condition of 8I1Y ccntr.ct or olher dOQumellt willi <br />respect to which this <:ertltl~e of Insurance may be islUod Qr \Q whIch n mey pert.oln. the insll/'ance afforded by lh~ polioy <br />d6llCribed herein is subjeollo alllha llloo., IlJlC"""iOllll. iln~ ~nditkm., !1Illuch policy. <br /> <br />~ <br /> <br />..&~ c. fJL <br /> <br />Alft'KlRImo RlPRiSEHTATIV! <br /> <br />III1tBl~T <br /> <br />EMPLOYBR'8 LrABILITY LrH7T rHCLUDrKG DE~KNSE cosrS, $l,OOB,BBB PEa OCCUKaaNCZ. <br /> <br />II;l'IDOUBJIBm 11500 - ROGIlIl l!'A1IIlIU., pas, se, TR - EXCLUDIlD. <br /> <br />2RDORS~~ '2065 ERrITLID CB~J:pJ:~a gOLDERS' NOTrCE EFFECTIVE 04-01"2004 rs <br />ATTA(!IIIlD TO llIm l!'OIlXS A PUT Ol!' TRIa J;>OLICY, <br /> <br />1#-2/ "ty <br /> <br />'I <br />, <br /> <br />e~R <br /> <br />,I , <br /> <br />ROGER i'ADIllIiL J'Ol!ILJ:C MtAUS Die DU., !fARM .. PADIlIIL <br />25 ORClUllU) <br />WlD J'ORlllff C.A ~~nQ <br />I <br />Ii <br /> <br />~'il~;1"- <br />