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<br />CERTHOLOER COPY <br /> <br />SG <br /> <br />STATE <br />COMPENSATION <br />IN SURANCE <br />FUND <br /> <br />P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br /> <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />ISSUE OATE: 01-01-2006 <br /> <br />GROUP: <br />POLICY NUMBER: 1500351-2008 <br />CERTIFICATE 10: 55 <br />CERTIFICATE EXPIRES: 01-01-2007 <br />01-01-2006/01-01-2007 <br /> <br />CITY OF SANTA ANA <br />305 E 4TH ST, STE 201 <br />SANTA ANA CA 92701 <br /> <br />SG <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 10 days advance written notice to the employer. <br /> <br />We will also give you 10 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, of such policy. <br /> <br />~ <br /> <br />~~t! <br /> <br />~ <br /> <br />AUTHORIZED REPRESENT A TIVE PRESIDENT <br />UNLESS INOICATED OTHERWISE BY ENOORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING: <br />THOSE NAMED IN THE POLICY OECLARATIONS AS AN INOIVIOUAL EMPLOYER OR A HUSBANO ANO WIFE EMPLOYER; <br />EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING <br />CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUOEO UNOER CALIFORNIA WORKERS' <br />COMPENSATION LAW. <br />EMPLOYER'S LIABILITY LIMIT INCLUOING OEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br /> <br />, ,'~ , <br /> <br />Received By <br />City of Santa Ana <br /> <br />DEe 2 9 2005 <br /> <br />Downtown Development <br />Division <br /> <br />X*'-~V~7 <br /> <br />EMPLOYER <br /> <br />TRAUTH,DENNIS WILFRED <br />21342 CONRAOI AVE <br />TORRANCE CA 90502 <br /> <br />SG <br /> <br />(REV.2-05) <br /> <br />e, ~-' <br /> <br />M0408 <br /> <br />PRINTEO <br /> <br />12-17-2005 <br />