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<br />SP <br /> <br />CERTHOLDER COPY <br /> <br />STATE <br />COMPENSATION <br />IN SUFtANCE <br />FUND <br /> <br />P.O, BOX 420807, SAN FRANCISCO,CA 94142-0807 <br /> <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />ISSUE DATE: 10-06-2005 <br /> <br />GROUP: 000364 <br />POLICY NUMBER: 0000202-2005 <br />CERTIFICATE ID: 612 <br />CERTIFICATE EXPIRES: 10-01-2006 <br />10-01-2005/10-01-2006 <br /> <br />CITY OF SANTA ANA <br />DOWNTOWN DEVELOPMENT DIVISION <br />305 E 4TH ST STE 201 <br />SANTA ANA CA 92701 <br /> <br />SP <br /> <br />JOB: DOWNTOWN <br /> <br />DEVELOPMENT <br /> <br />This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the <br />California Insurance Commissioner to the employer named below for the policy period indicated. <br /> <br />This policy is not sUbject to cancellation by the Fund except upon 30 days advance written notice to the employer. <br /> <br />We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. <br /> <br />This certificate of insurance is not an insurance policy and does not amend. extend or alter the coverage afforded <br />by the pOlicy listed herein. Notwithstanding any requirement. term or condition of any contract or other document <br />with respect to which this certificate of insurance may be issued or to which it may pertain. the insurance <br />afforded by the policy described herein is subject to all the terms. exclusions. and conditions. 01 such policy. <br /> <br />~ <br /> <br />,d~~ <br /> <br />&L- <br /> <br />AUTHORIZED REPRESENTATIVE <br />EMPLOYER'S LIABILITY LIMIT <br /> <br />PRESIDENT <br />INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE, <br /> <br />ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2005-10-06 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY, NAME OF ADDITIONAL INSURED: <br />CITY OF SANTA ANA <br />ENDORSEMENT #1600 - JEFFREY LOPEZ PRESIDENT TREASURER - EXCLUDED, <br />ENDORSEMENT #1600 - NANCY LYNN LOPEZ SECRETARY - EXCLUDED, <br />______ ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 10-01-2001 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br /> <br />EMPLOYER <br /> <br />.. ,) AS TO FORM <br /> <br />1~~e~7 <br /> <br />City Attoraey <br /> <br />DEKRA-LITE INDUSTRIES, INCORPORATED <br />3102 W ALTON AVE <br />SANTA ANA CA 92704 <br /> <br />SP <br /> <br />(REV.2-QSI <br /> <br />PRINTED <br /> <br />ICMJ,SC] <br />10-06-2005 <br />