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<br />
<br />DATE.w..r;iiOlvv} ~
<br />07/07/1999
<br />
<br />~O Uu 70-18
<br />U3 City B.lvd.. Wl!.st, Ste. 400
<br />range. CA 92!6~~/048
<br />A!tn: ^p ,n w.l k. r
<br />lIlWilEb".... '" "..,........................,.. ..,..
<br />CalP.o.~~ LlC
<br />On-Sit~ Fabr1car~ Servicet LlC
<br />1111 AlJligQ~ A'lt'enl,je. Suite B
<br />OQ~ncy. CA '0242
<br />
<br />E.I: -166
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<br />
<br />lllll Y AND l;llllFER:5 NO RIGHTS UPOII T~l! CERTIFICA 11i!
<br />HOl~R. THIS CERTlFICATE DOES NOT AMEND, EXTEIlD ~
<br />AI.1ERTHE COYERAGE AFFORCEC BY THE POLICIES BELOW.
<br />COMPANIES AFFORDING COVE~"
<br />"oo'Mp;:;;':"'"''''ij"i't'e'd''' 'Sta-t-~s'-"F'i-t; -i~'~':' "'C~' ..
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<br />Inc.
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<br />i PDIJt'f' EFFEC'TlYE POUCi' ElCPIRATlON
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<br />;:~l"'''''' ClAl~ MADE [.");".1 OCCUR!
<br />A ,""l.... ;..... ;10~0030967
<br />, OffflER''s & CONTllACTOq'S ProT :
<br />
<br />10/01/1996 ' 10/01/1999
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<br />ALL ()INrED Auras
<br />SOIElUlID IJ,ITOS
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<br />ill' 6 2" 9 68
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<br />i 10/01/H9!
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<br />; BCI01L.Y INJURY
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<br />. X HIRED AUTOS
<br />; X HON.oWNEO "\,Ires
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<br />10/01/1'9'
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<br />! PROPERlY 1)M(ACf! , S
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<br />, GARAGE UABl1JT'f
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<br />: AUTO ONLY" QACC.lPIiffi" S
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<br />: 01/01/1999 .01/01/2000
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<br />"'SGIlf:GIlm :5
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<br />'ELDISEASE-'EA1:ti.1rtoYtt:$ 1,OOO~OOO
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<br />, EXC:f.SSl1A81LrrY
<br />UMBAEUA FORJ,I!
<br />OTHER~ANUMBR8lAFORM
<br />, 'M;IIIIlKER5 COlfPENSATTON AND
<br />. EMPf.O'\'ERS' UABIl.Jn
<br />
<br />DUCAlPTJQN OF ap9AA1IO....QCA"T\CIHStV..ttl;I.liiS..1:lAL rrEMS
<br />HE CITY OF .AHTA ANA. ITS OFFICERS. AGENT,' EMPLOYEES ARE NAMED As
<br />
<br />DOIrIOHAl INSOREO PE. FORM FMI01.1.1'59 ATTACHEO.
<br />
<br />10 OAYS NOTICE Of CANCELLATION FOR NON~PAYMEHT OF PREMIUM
<br />
<br />~..=""=::.,,""'!,,:~"'''',..''''''_:.~!
<br />M . '.K__ .. J~*~~.~;t,:aro-~:~~!ti~.Mt:''!",:..t~.... ".:~~,.:::,.......,
<br />
<br />CITY OF SANTA ANA
<br />ATT~' OORIs TORLEY
<br />FAX ~71'/6'7~69.6
<br />PO SOX 1.88 M~Z5
<br />SANTA ANA. CA 9170Z
<br />
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<br />sHOOlDNf'f (I" IIlE ABOVE mSCRlBEO 'POLICES 8'E CANCEllIm DEFORE THE
<br />DPlftATlOM DATI!! y~.u..o,. n1f tSSUINGCOMPANV WILL .~!lRftl'IIl MAIL
<br />-6L DAYS WRITTEN NCmCI. TO~I!. CEll'mFlCA1E HOlDER HAlED to 'nU! LEFT.
<br />N_~l!llIl~Il!_IIll~lIXX
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