TUSTIN IRVINE MEDICAL GROUP 1 -2003

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~ CERTIFICATE HOLDER COPY STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807 COMPENSATION INSURANCE FUN 0 CERTIFICATE OF WORKERS' COMPENSA TrON INSURANCE SEPTEMBER 12, 2002 GROUP: POLICY NUMBER: 1443685-2002 CERTIFICATE 10: 4 CERTIFICATE EXPIRES: 04-01-2003 04-01-2002/04-01-2003 CITY OF SANTA ANA ATTN, JEFF STEVENS, RISK MANAGEMENT DIVISION 20 CIVIC CENTER PLAZA, ROOM #M28 SANTA ANA CA 92702 JOB: CITY OF SANTA ANA AUDIO TESTING This is to certify that we have issued a valid Worker's Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer. We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or may pertain, the insurance afforded by the policies described herein is subject to all the terms, exclusions, and conditions, of such policies. -d /~" ~ f(e4o-l-~~'~ PRESIDENT AUTHORIZED REPRESENTATIVE EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS, $1,000,000 PER OCCURRENCE AI'FRO V bJ AS 10 IORl'vJ ~y 4::aura ShC~ Deputy City Attorney EMPLOYER JOHN G ALEVIZOS, DO. INC AND TUSTIN-IRVINE MEDICAL GROUP, INC DBA, JOHN G ALEVIZOS, DO 800 N TUSTIN AVE STE A SANTA ANA CA 92705 selF 10265 IEPF-UI, AE 1