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<br />. <br /> <br />SP <br /> <br />STATE <br />COMPENSATION <br />INS UA A N'eE <br />F=UNE) <br /> <br />,>-' <br /> <br />~RTHpcD~R COpy <br />A~ 2- CJ 02 ~o1!J- 3 <br /> <br />PO. BOX S07, SAN FRANClSCO,CA 94142-(}S07 <br />" ., ,', .. -," ....... ,.......... .. ',. .. < <br /> <br />.. .......... "::".: .......c..:.::....:_' <br />CERTIFICATE OF WORKERS' 'COMPENSATION INSURANCE <br /> <br />, <br />,<-,,_,S <br /> <br />ISSUE DATE: <br /> <br />04-01-t003 <br /> <br />GROUP: 000488 <br />P<JJ.,ICY l\IUMB~R: 00001BB-t003 <br />C~RTIFICA T~ 10: 18 <br />"bER'fll'lCATE EXPIRES, 04-01-2004 <br />04-01-2003/04-01-2004 <br /> <br />'-'~- ,. <br /> <br />"-',C-,";-' <br /> <br />C \.TY OF SANTA At>iA <br />ATTNLUCY FLOR.ES <br />PO BOX 1988 <br />SANTA ANA CA 92702 <br /> <br /> <br />, <br /> <br />This is to ce_rtif,v.. that .. ~e have_ issued a ;valid_ "Yorker,s: C_?rn~1Jt;$j~~:.in~~~nc_~_ poHcy-in.. s_formapproved by the <br />California Insurance Commissioner -to the ~employer named beiC\V'l~r~:ti;1.e P51icy period indical"ed. <br /> <br />This policy is not subject to canceHation by the Fund-except upon 10 days' advance written notice to the employer. <br /> <br />We will also give you 10 "OaYS' advance notice should this policy be cancelled prior to its normal expiration. <br /> <br />. .. ..' <br />This certificate. of,:-insurance is .noi an in~ur~nce policy ana' .does....not amend.::: e){t.e;'d/oralter the c::overage afforded <br />by the PCJhcjes.,Jisted her~in>NatwIth-stant.iin9anvrequire11"J$f"\t..t.rf'rl.or COr'ldit,iol1.': o.fany cqntract qr'other, documtl.nt <br />with resp~ct: to which this"-certificate off: in$lJranq;Er"l"1"I~Y'tJ.e'.:l.s$ued.pr:mavpert,in.the ,'insuranceafforded'.,by the . <br />policies described herein is subject to a!1 try9 te~m.$' excl~sjons: anacondidons' of such policies. <br /> <br />/,4:.. ~-r.f^ <br /> <br />- <br /> <br />A~c <br /> <br />&ii- <br /> <br />AUTHORIZED REPRESENT A TIV~ <br />EMPLOYER'S LIABILiTY LIMIT INCLUDING <br /> <br /> <br />PRESID~IIIT <br />$f.cioo;~,oo PER OCCURRENCE. <br /> <br />AFPROVED /\S TO rORM <br /> <br />L~~/~ ------ <br /> <br />D~pulYClly Attorn;,y <br /> <br />EMPcOYER <br /> <br /> <br /> <br />NAME <br /> <br />ANAHEIM INTER.FA:ITH <br />INe . . <br />626 N PAULINE ST <br />ANAHEIM CA 92805 <br /> <br /> <br />~EI~ 'INTERFAITH SHELTER. INC <br />(lI1<<lNl PROFIT PUBLIC BENEFIT) <br /> <br /> <br />PRINTED: 03-17-2003 P04D8 <br /> <br />selF 10265 (REV? (1) <br /> <br />'~ <br />