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SC I <br />I CYHOLDER COPY <br />STATE P.O. BOX 807, SAN FRANCISCO,CA 94142 -0807 RECEIVED MAY 2 6 2005 <br />COMPENSATION <br />IFUND NS U F:AN CE <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 06 -30 -2005 GROUP: <br />POLICY NUMBER: 1696570-2005 - <br />CERTIFICATE ID: 3 <br />CERTIFICATE EXPIRES: 06 -30 -2006 <br />06- 30-2005/06-30-2006 <br />CITY OF SANTA ANA SC <br />PO BOX 1988 <br />SANTA ANA CA 92702 <br />This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the <br />California Insurance Commissioner to the employer named below for the policy period indicated. <br />This policy is not subject to cancellation by the Fund except upon 10days' advance written notice to the employer. <br />We will also give you 10 days' advance notice should this' policy be cancelled prior to its normal expiration <br />This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded <br />by the policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document <br />with respect to which this certificate of insurance may be issued or may pertain, the insurance afforded by the <br />policies described herein is subject to all the terms, exclusions and conditions of such policies. <br />X . <br />AUTHORIZED REPRESENTATIVE PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000.00 PER OCCURRENCE. <br />APPROVED AS TO FORM <br />Laura Stitt Sl edy `. <br />Aseistaot City .'Attorney <br />EMPLOYER LEGAL NAME <br />THE CAMBODIAN FAMILY <br />1111 WAKEHAM AVE STE E <br />SANTA ANA CA 92705 <br />THE CAMBODIAN FAMILY <br />MEV3-03) PRINTED: 05/17/2005 P0409 <br />THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND saF 1026, <br />