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08/22/2005 23:17 5652602 <br />5/1,7/2005: 18:55 3108941065 <br />WORK CENTER <br />HR MANAGEMEI4r.5ERVIC <br />PAGE 02 <br />154GE 03 <br />fiC <br />POLICYHOLDER COPY <br />TM P.0.80X807, SAN FRANCI$CO,CA- 94142.—QW7 <br />1Nf/J AMG.� ,,. .• , <br />F�a MS cwnFlICATR 0 woJ%KkRa ct 04ATn011%*AURANCE <br />ISSUE DATE 12-011-2004 ORGUP: <br />POLICY NUMIIIM; 1014IA0^I00a <br />.. CERTENCAIT IS, 27 <br />,. ,C1314tikICAftil WKIPI Sr 12-01-2000 <br />.i 14=01,2 /12-01-lOOs <br />CIT•Y'OF SANTA AMA SC' <br />ATTN MANAGER OF,WIB-ARMIN OFFICE <br />1000 SANTA ANA BLVD GTE 200' <br />SANTA ANA CA 927Q1 <br />This is to oarilfy that we hove issued a valid Workers' Cbmpensetion insurarce Goliov In ■ Form approved by the <br />CaNfamis Insurance Csmmistlansr to the employer named below fbr the policy -period indicated <br />This Polley In not Subject to eg0111011idn by the Fund except upon so dayd advance written notice 10 the employer, <br />we will else give you 20 dsy"si 'WV*46 notice aho4td this pvtky be cantleFlad 'prier to Its irormd exPlrad0nl <br />This certiflosts Of ifleurancs in mat an insurance policy aril does Act r+t4nq„ exland or miter the covera0s afforded <br />by the palicibs listed harain, any reRvlrixirtAM , term, or cogdlllad of any contract or other' document <br />wRh na0ert to vvWloh tMs oertl bats at anaurartae may b/ L�aue4 ar nuy, peryte„'tga nWM10e sffMded by the <br />policies daceribod herein is subject to alb the 1147 ; ext:16 tl'tte 4 aanditiahs of such pollelell <br />A,� VXIL.' <br />AUTHDRIZED REPRE.5ENTAnve PRESIDENT <br />EWLG-fnR &,4IAIILIf1'Y'1,1<MIT, f*LUDIMO OCFFs46E,;iM>rllf; s,4,000,;Cs0.00 PLI!•OCCUIlIENCE. <br />a <br />Eta)l*scvsmt 02040 INTITLEb CaTUPWAtt .HOLDERS' spret 1YYE �0-0.1-3004 �:6 ATTAt HRO 70 AND <br />F011115 A PtIRT OF --;His PaLrOy."'. <br />Ir ,..', <br />. 11 <br />APPROVED AS TA RojM <br />,,. <br />'' ... di -trots. Stitt She y <br />ASSiStanf City Atlnrney <br />EMPLOYER "„ v:, .' „LLOAL "at <br />21 <br />' NIiMAN nEiQlf/U:E 11 t 9;Milk; VICES *1y�A NINYIIIA1E601 MAI�RgTAIlr's[Ivic[s itlG <br />1))17r.RISlNC _IFll 40■ <br />