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P 002/003 <br />MRy-19-2005(TMU) 09 51 <br />, 7f <br />~' ~ ~"~r,.; ~' i• yt`~r. -"tr'?~r ~' Icy i1 t mot' <br />r c .r1 <br />~ '~I~~I I Ir ~'.f ti v,i5. <br />~TA~~~ ' F' O ,60~f8OTrSA~V~FRiCNCI <br />':COMP6NSAT07N r ~ ^ ' 1 ayLll 9I at ~ ~ ' <br />~ rwFSU'raiKN-ee - S'2..1e1' , ~+,Yfr ']wt Il~t <br />~-f ~, ^ ~ . , <br />C"V,~-~ CERYIFICIITEi~OF WOEiN;ERS"G( <br />ISSUE-OPTS 12r:D1~20O6 !~ ~'~ ~^ - I <br />r , ,. <br />`, i'I <br />I I ~ Il l~~l~l-~j`1 ~~f <br />II ~udNlrf <br />X11 Ir a ~f ~~, ti~ <br />I ~ TpL Is [^ o canlty [hit: wo~' ham v~d v~~~~IPrker~ ~mpansu ok <br />Cat{fomla Ipduraneel Calnmlceto~or r~to thol amp~,yer~ Vtnedf~lol~~~,r <br />l ~ ~ j ~ . t ~i . , q s ~'' .'~ a,, c 'try, <br />, <br />7efs pollcv I:"not ubfecl io,cancillutlon~4fFraher Fupd llazcepG hpon.~ <br />:.'c' ,.l y;ly r. l',f 6. w,li ., i.;l~, y 5i~;:f sir ~'ilr . <br />Wa will also 91va you 3p'~ddy^~ ~advar¢e notice,: chdUld ,ifil71;pollcy Na. <br />Thli cartltlcA[o o} ,Insu <br />~,, -by,,[ha'-pollda».11;[bd-h <br />' 'with„ta=pdgc~td,NibleM <br />~poUelas de erlbed hero <br />I .." ,. <br />a'': <br />,- .~nuTNOP12E0,,REP,,RESE'~ <br />~''- ~ ' ~EMPL'01(ER f S `LIABIL: <br />-;t, Qp100{LSEMENT M2085~ <br />-,FORMS A PART OF T1 <br />~t <br />H all <br />t <br />I <br />o , <br /> <br />r. , . ;. <br />~ . , <br />sc <br />~ <br />. ~. <br />1,~ i ... _~I t r, <br />' I' ~' C <br />, ,. ~POLICYHOLOER COP'/ <br />~ ' ~,I ; <br />, <br />'r.. .' <br /> ~~ ,; ., <br /> <br /> <br /> <br />' <br />' <br />' 000834 ~'y '• <br />' <br />,0000421-200a <br />JM9EP.' ~` <br />~ I <br /> <br />F-~•.c /frrfrN1, :;YS t ~,~ 11.r+1i ~'>/4 jrf N l~roi7~?iw•~~lhcl- <br />` . , ,: <br />r , a ; <br />I,,,S, .` y ,I'".r~Tt lll, ~y V'~~S ~'~ u.I i~+~_h ,; I' <br />1 <br />.I l t a ~ \ LI'11~ I 1._~'~ i <br />K y t II <br />-rtr a <br />p 2paillcr ~tl n l }orM[ approved hyl 'hah ~ ya , r ~ ~, m l <br />-y~Porfdd'Indlc~tdd r 'r ~ 1 L .,II \*I'i <br />t s fi i h 4. <br />1. ~ ~Y. , tC .,. x.t \ <br />r <br />dVarjca`Mltlnen'notlca tol[Ae etnplayel,-j' ,~~ t1 ,~ n! I~ <br />,...-. . ~. ~,. I, <br />d~p[lor [o au naemal axplratlon... ,- <br />r [r +. <br />[heC)[o~mtt aXeJLda~a'~nd~cd(rpp~''dltlol(t3"dl~edc po ce ri t , r i a - <br />\ ^~i•. 7 v. Jlk ~y L'(~,` t'.I'Ja ', ti11. / yi 'aly~ r IA r~..~ r "rfT Valrld t. <br />it , f J . ~ n I r ~ !~.nlf\J ! ,t <br />a1`~1V~ IK ,M iL~S~~~tiFt ~ ~~f ..r t,A• (//t~~//t~~ ~, f I'i ,ir 1 1, ~ynl' 1 <br />4`~,i yCl} J'?S ".IVi'\I /~~~4 I I `~/„~.'. ~ ~,r I I 1 \1 r r~l <br />11 14j F I Jry ~,ytl`itV IlK l.i ,l Y roA y'f .i N :i 1, I {i 1 I. inl <br />'IOI 4~ i .1 ~ 1 ~ 7P ~' K 1 11.,! w .:J .f ~L,e a I, ... , Mtll'~} <br />ra',, . ! ' ~ ~ , <br />ING?'DEPI'NSE, COSTSI 'R'.Y`I' 000° Od0;~`00 `PER-OCLIIHRENCE'=; - . , <br />'I,. :I ~~j 4{. ?.~-'Il~ttt'rlf,.^~Y'+r :IT :~\rn ~',.., R:.. '. er . <br />2GAT6 pOlOERS, NOT E:'EFFEGTIVE 72 0Y-Z0041"IS 0.TYpl]iED TO,,ANO i ~. ',~ .';I <br />I <br />,1e ~ NS t Ia 7,yly itv+ 1 I r / r i ,...> 1 <br />. .:r It I •l 'Ii I~... ~ ' 'L_ _1 _ •.v .., .n. <br />I i t ~W~ , ti 'i ' `Yt`ph- fit, I r'+... ~' 1 ...alt,-d'f 1 tA.;I dye . <br />I I I I <br />I t` :l rf ~ 'I'v yr 'I 11 w M1 'I:`M Y IY 41. ~ ! 'ILf YAt't1~f'11/4' '4. t I , r S +, ~7Ys ~ , ~r If~,l (4 r~• <br />t L t n. ' lY, 1 fy'11M1.>..t a' I I u~ 1 ~.. ' i~~ <br />l ~ 'ar 'uC. IC xr l~, '. .r Sr/'rr 1 r• w leRr ..y~ I ~: n 1 '.. r. vl ,f /rtt' r a-"~ <br />1 ' K'~R~le+' r , ~ tP T ~ ,I k / , I yr t:, y tt w r -ti+t I-' x <br />., ' \ , ' rY~µ; t, yl.µ ~l rr,tLl w. r ,d.~lf r,~^l.L!.~'~ 1 .'~+,; ! ., 'd•.• ,.. i <br />I ( , <br />' I ~ r 1 t'-T,' ,.. ~ .. .. <br />I tl, 'i nl Jf...y h ~ ~ .. , <br />., rl .. ,. (.. r..r r>71, . <br />- APPRC3VEU fiti Tt) f~'vi~~3 „ ' "•I .. „ <br />a , <br />y <br />e - ,, ~ I'wSb]St3rii liiy rAPlvn'nceR .. <br />I <br />I <br />Y , <br />~ A I .... ' it f <br />L f.l' an,.. Lr'f <br />EMPLOYER , . .. ~ • •.. ~ ~ ~ ~ , UEOAL NAME - .. J, <br />f~.~ .. , <br />' WESTCLIFF'ME^I CAL\ LABS ',`~ WESTGLIFF MEDIG[l IA85, ETAL. <br />1821 E DYER RD ST,E TOOK I „' , <br />SANTA ANA CA 92705 I <br />... <br />...•,..~ ~ PRInITFn t'+/»/2ooa .....to <br />aFV 1 osl ~piiRCS~r.71Trf31~i`I C~ fltFf3)'6"i3 I«3>t rT~ <br />