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JUL-29-2005 09:BBR FROM: 'Q: 17146476549 P.2 <br />l'7~292005 07:47 fJ~.439 D002 <br />SP <br />POLICYHOLDER COPY <br />STATE P.O. BOX 420607. SAN a=RANCrSCO,C1+ 94142-OB07 <br />couaews.-rloN <br />ru5UaANCE <br />FUND cEaTIFICATE of WORI~RS' canlwenisAroni tNSU~aNC~ <br />SSSOE PATE: 07-28-4005 GFlOYP. <br />POLICY MAr6ER 7711151-9005 <br />CERTIFICATE 6T ~ <br />Ct3tT1FlCATp E%PVtE5:04'14'2006 <br />a- t4-:oosla-t4-4oti5 <br />THIS CEA71fICATE SUt•ER5EDE8 A!O COIbtECrS <br />CERTIfIGTE ^ 9 bATEb 07-41-4005 <br />CITY Of SANTA At14 <br />:t0 CIVIC CLIREaI -LAZ~ <br />SANTA ArttA G~ 1lTO! <br />6P <br />This b b wrHfV lfut va4 hwe IaH+ed a valid W0rk4ra' CeRWnaat{OA htaurMKe pe6ry M a form aOprWW M era <br />CaN}omh InsurMta GarsMaden4r m the atttPbver rraened 6altm a0r the poles P4rlod 1rxSOat4d <br />Thn policy la rot lublaot m canoM4e0n sY tM Fred except upon t0 days advare4 wrltun notlco m the emplOPen <br />Wa wiN also slue Ve0 t0 dM advanu naou eh0rad this poky be eannlled PrIOr m hs rxrrrtul 4xPdrklert <br />This aerditaeb of UK{l411p is rot h irwarce pokey an0 rhea not amartQ extend Or M1er the G0v4ra0e attrxded <br />by the po1oY pstad Iwain MOMfitlntwdtr~p arN reOuirMnsnt. term ar eeardidOrr of mY e0n1'a0t rx otMr doeanmM <br />wRh rapes m vdtleh ih& certlfkata of Yravanca mry he isausd Or fo wNCh it Mal Pertaftt tde arstranee <br />siforded bV era P06cY daserliad hrein k suE~eet m dl dre bans exeksiona. +d eand76ons of srreh p01i0V• <br />~~/~,oz-- ,dam- C . 6,~4... <br />AU1LdtN11FD REPR63fNTATIVE PNESCENt <br />EMPLOY11t'1 LIAtILfTY LIMIT IAGWDINB bEFl7a1E Lb5T5: 11,000,000 pER ppt;{IpIpICS. <br />~. _ <br />R,~V:iia iW <br />.~ T Y~'s~" TOROK <br />LISA E• S Attorney <br />~' Assistant City <br />EhehLOYFIt <br />ORAaIIti GOLIJYY CHiLOREMrS 17iCRAPEUTC ARTS <br />401 N 51bDA0YAY <br />SANTA ANl1 /:A 12701 <br />.SP <br />(MGS,CrTj <br />-RiatTEO r lYt-29-2005 <br />aiLN.YOq <br />