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' CERTHOLDER COPY SC STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 q, ~cOO~ _ ~~ ~- COMPENSATION ft INSURANCE FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~ ~ °~~ Jr - I' ~ - 0 ISSUE DATE: OS-02-2007 GROUP: POLICY NUMBER: 7880289-2007 CERTIFICATE ID: 23 CERTIFICATE EXPIRES: 04-01-2008 04-01-2007/04-01-2008 CITY OF SANTA ANA SC JOB:ALL CALIFORNIA OPERATIONS ATTN: SHAHIR GOBRAN 20 CIVIC CENTER PLZ M-43 SANTA ANA CA 92701-4058 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the Calif orris Insurance Commissioner to the employer named below for the policy period indica[etl. This policy is not subject to cancellation by the Fund except upon30 days advance written notice to the employer. We wilt 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 antl does not emend, extend or alter the coverage afforded by the policy 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 to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditiens, of such policy. V THORIZED REPRESENTATI PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT X1600 - ABRAHAM TASHMAN PRES. - EXCLUDED. ENDORSEMENT #1600 - MICHAEL BLITZ CFD SEC. - EXCLUDED. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 04-01-2007 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER NATIONAL DATA AND SURVEYING SERVICES INC OBA: FIELD DATA SERVICES DBA: SOUTHLANO CAR COUNTERS 8370 MILSHIRE BLVD STE 209 BEVERLY HILLS CA 90211 APi ~r>=,' t-~) J,h:}~TO FORM Assistant City Attorney [SLC,SP] IREV.4-06) PRINTED OS-02-2007