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f SP <br />C HOLDER COPY <br />STATE E P.O. BOX 807, SAN FRANCISCO,CA 94142 -0807 <br />COMPENSATION _ <br />INSURANCE <br />FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 06-01 -2005 GROUP: 000723 <br />POLICY NUMBER: 0000075 -2005 <br />- CERTIFICATE ID: 2 <br />CERTIFICATE. EXPIRES: 06-01-2006 <br />06 -01 2005/06 -01 -2006 <br />CITY OF SANTA ANA SP JOB: <br />COMMUNITY DEVELOPMENT AGENCY <br />PO BOX 1988 M -25 f <br />SANTA ANA CA 927!02 <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 />This policy is not subject to cancellation by the Fund except upon 30 days' advance written notice to the employer. <br />We will also give you 30 days - advance notice should this policy be cancelled prior to its normal expiration. <br />This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded <br />by the policies listed' heroin. 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 may pertains the insurance afforded by the <br />policies described herein is subject to all the terms,: exclusions and conditions of such policies. <br />AUTHORIZED REPRESENTATIVE PRESIDENT. <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000.00 PER OCCURRENCE. <br />ENDORSEMENT #00.15.. ENTITLED.. ADDITIONAL. INSURED EMPLOYER" EFFECTIVE... 06-01 -2005 IS ATTACHED TO AND <br />FORMS .A PART OF THIS POLICY. -_ <br />NAME OF ADDITIONAL INSURED: CITY OF SANTA ANA SP <br />'ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 06 -01 -2005 IS ATTACHED TO AND <br />FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />APPROVED AS To FORM <br />3 alfra Stitt Sh Y <br />Assistant City AttorneY. <br />._LEGAL NAME <br />BOYS AND GIRLS CLUB OF SANTA ANA <br />950 HIGHLAND ST <br />SANTA ANA CA 92703 <br />(REV.3 -03) <br />BOYS AND GIRLS CLUB OF SANTA ANA <br />(A NON PROFIT CORPORATION) <br />PRINTED: 05/17/2005 <br />