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SP <br />HOLDER COPY <br />TUP.O. BOX 807, SAN FRANCISCOCA 94142-0807 <br />CbNSATjbNrt'd NC.E. - <br />�U © CERTIPICATE 60, WORKERS' COMPWATION INSURAM1(CE <br />. '1$SUE DATE: 09-01-.-2004 <br />CROUP: <br />POLI,Ck,NUMgER:� ,077e31y=2004 <br />� RTI ICATE fDc .! 02. -. <br />CC-FiTiFI�AT EkPIR�'S: Oe?s.Q1-2005 <br />CITY OF SARTA ANAL° Sp <br />�TTW JOHN MALONEY <br />�. 20,�CFVJCi .9.ENTER PLAZA <br />:SANTA ANA., 32702 <br />ti h <br />This is to certify: that, we have issued' a yalid Wgikere Co pang insu e' Polity 7o a <br />California 1,hsurance. Commissioner to the:.empl4§yer erred beioW f' t Fz q y 1� approve¢ by the <br />. � R0I.1c7e; PeriofJ tndieat`eid ,.,_- <br />„TMs,policywis not subject to cancellation by,th6 Fund except upon 30days arjvarrGe written notic 3o the ePnplpyer. , <br />We will ($;r? give'yqu 30 ?lays' bdvance�'irrESffc9 should tf policy be carl'F;glled4wioato i'� normal �*Piration. <br />This G,�rtificate of in$urance is,nQl arN insure a pofiCy a s <br />J , by the polteies Iisted' herein. No`tVoJhstan n e DOI atnapdj, extend iSr y,Rer the 44Kdrage affordetl <br />with respect to wMefx this cefitificZt' a of n 2rr Y r`equire0t00 term, or co�kpn of ahK�etst+tyAct o1. 0 .document <br />arcs, maY'+t issuelJ or may pertatry the IrfgtJlan@@ yfforf(eby the <br />poNcies described herein is suk)ect to all ihec,tern7s, ex'clusrons af)d1� Oiiditions of §ueh "pplrcies. <br />AUT14CRUEDa REPPESENTATIVE <br />EMPLOYER'S LIAat,LITY LIMIT INCL6OING REEENS"E :.0 tSFS'"��St,, Opp; CM ®T1;PER,OeCURRENC@`. <br />ENpORs€,MENT, H205f5' ENTITLER CERTIFICATE, N,pltg�ERS`` NOTICE, EFEE,CTIS(E 09-Ot"-2004';IS �ATiC'hIER'..TO AND <br />.`. F?ORMS-A PART,OF TJI,YS OOLIey. ,,_ <br />s <br />`'+ <br />li l l <br />Np x� <br />9 <br />Ar k iy •� <br />� <br />� n <br />a <br />Y, k <br />EMPLOYER - r^ '" o <br />`y, x <br />a <br />r a <br />LEGAL, AID SOCIETY OR ORANGE LEGAL AIo_'sQCEiY OF okANE CotlltTl•' <br />C6l1NTY ATTN: JAN MIC}#AEt <br />9O`Z . N MAIN ST EA,'NON=PROFFT i (ARE.') <br />SANTA ANA CA 92701 <br />I.REy.3-031 [a <br />�nh•r _ PRINTED: 08/17/200M1 ,:P040A <br />