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t I ! <br />STATE <br />COAApicrquAnew <br />INSU114ANCR <br />FUND <br />CERTHOLVER COPY <br />P.O, BOX 420807, SAN FRAIYCISCQCA 24142-0807 <br />CERTIFICATE 100 WORKERS' COMPENSATION INSURANCE <br />ISSUE OATS: 09-19-200s <br />CITY OF SANTA AMA <br />20 CIVIC CENTER PLAZA <br />SANTA ANA CA 02702 <br />GROUP I <br />POLICY NLPAIXR;11354520-2001111 <br />CERTIFICATE Ilk44 1 <br />CERTIFICATE EXPIRES: o7-01 -goo@ <br />07-01-2005/07-01-2000 <br />SP d00:ALL CA OPERATIONS <br />This N to certify that we h2vQ 191U90 A Valid Work" conVilmsmfor, iftArence policy in 3 form approved by the <br />California insurance Corrn.19slamar to the employer named below far the Policy Period Indicated. <br />,rhi policy s nj subje*t to tncollation by the Pund 4xO4Pt upon 00 data advance written nOtibe to the employer. <br />�IWe will elsp <br />Give 'Y6u3Q:daya; advance notice Should this Policy he cancelled Prior to Its 4MM&I expiration, <br />Thia cardtfoata M Insurance Is not an Insurance Policy and 4095 not amend. extend or after me <br />by me polio (is erahNotwithstandingcovarage afforded <br />with rows to hie this to *fi of Insurance <br />requirement, term or condition Of NV Contract or other document <br />afforded by the I described rs I surance may be teamed or to which It may Pgrt2ll% the ih5wrahoa <br />In a subi9et to all the terms, exclusions, and conditions, of such policy. <br />AUTHORIZED REp"gSENrATIVI! PRESIDENT <br />BMPLOYER'3 LIABILITY LIVET INCLUDING bErSNSE COSTS! $1,000,000 PER OCCURRENCE., <br />ENDORSEMENT #1901 - JOSEPH A HENNISSEY EXCLUDED, <br />ENDORSEMENT #1901 - SHARON A HENNESSEY gXgLUDEO. <br />ENDORSEMENT #RON ENTITLED Ci!RTXPICATIR HOLOCIRS, NOTICE EFFECTIVE 07-01-210931 IS <br />ATTACM TO AND CORMS A PART OF THIS POLICY. <br />1511MLOYER <br />& HENNESSEY, LLC (A LIMITED <br />COMPANY) ' <br />I ST # 4-2511 <br />02700 <br />6P <br />.AS '1'0 FORM <br />0/ Atiorady <br />MS.CNI <br />PRINTED :.0off14-2005 <br />PAGE 02/02 <br />8115 <br />HSI <br />II <br />