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CERTHOLDER COPY STATE P.O. BOX 807, SAN FRANCISCO,CA 94142 -0807 COMPENSATION INS UWAN C6 FUND CERTIFICATE OF WORKERS` COMPENSATION INSURANCE ISSUE DATE: 06 -01 -2005 GROUP: 000723 CITY OF SANTA ANA SP WORKCENTER ATTN: ANABELL YATES 1000 E. SANTA ANA BLVD., #200 SANTA ANA CA 92701 POLICY NUMBER: 0000075 -2005 CERTIFICATE ID: 1 CERTIFICATE EXPIRES: 06 -01 -2006 06 -01- 2005/06 -01 -2006 JOB: ALL OPERATIONS This is to certify that we have issued a valid Workers' 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 30 days' advance written notice to the employer. We will also give you 30 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 of 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. X c . AUTHORIZED REPRESENTATIVE PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000.00 PER OCCURRENCE. ENDORSEMENT #001.5 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 06 -01 -2005 IS ATTACHED TO AND `.FORMS A PART OF THIS POLICY. 'NAME OF ADDITIONAL INSURED: CITY OF SANTA ANA SP ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 06 -01 -2005 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER BOYS. AND GIRLS CLUB OF SANTA ANA 950 HIGHLAND ST SANTA ANA CA 92703 LEGAL NAME BOYS AND GIRLS CLUB OF SANTA ANA (A NON PROFIT CORPORATION) InEV.3 -03) PRINTED: 05/17/2005