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<br />S'TATE
<br />COMPENSA1'"iON
<br />INSURANCE
<br />FUND
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<br />P.O. BOX ~07, SAN FRANCISCO,CA 94101-0$07
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<br />CERTIFICATE OF, WORKERS'COMPENSA T10N1NSURANCE
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<br />ISSUE DATE: 10-01-02
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<br />POLICY NUMBER: 1209902 - 02
<br />CERTIFICATE EXPJRES:l0-0 1-03
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<br />C.I TY OF SANTA ANA
<br />COMMUNITY'OEVEUOPMENLAGENCY M-25
<br />POBOX 1988, :ATTN eJOHN'MALONEY
<br />SANTA ANA CA '9270~ .
<br />
<br />
<br />This is to certify that we have issued a valid Workers' Compensation insurance polic{'in a -forni"approvedby^the
<br />California Insurance Commissioner to the employer named below for the policy perioq_indicated.
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<br />This policy is not subject to cancellation by the Fund except upon 30 days' advance written~o_tjce t~.__theemployer.
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<br />We will also give you: 39 d.a'ysi-a9va~ee notice should this pOlicy be cancelled prjortojts,:norniaf~xpiration.
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<br />This certificate,'bf)insur~nce_ is ,,' not, an insurance policy and does not Jme~d/ eXlend or-alter__ tt1f3,co"erag~:afforded
<br />bX the pQlicies li,$te.d her~in.<,_~qt~ithstand~~g any_requirl!I'I'J~~t, term, or corydit!o,ry' q1 ;any contra,c,tor'ptherdoculT!enL,
<br />with resp~ct to Which thiS certificate of_ Insural')ce :.mayl?e-~I~sued or may pertam,:,the Insurance ',afforded:by the "",,~
<br />policies de~crjbed herein 'S subject to tdl the t,rrrjs,excl~sj~ns and conditi~,ns ,of such policies.
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<br />EN60.~SEMEm.#20llSENTiTLED CERTIFICATE HOLDERS'
<br />fORMS A PART Of THIS POLICY. " '.
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<br />EMPLOYER'S LIABIL~TY LIMIT INCLUOING DEFENSE CDSTS:
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<br />$1,ood;o~.oo PERjoCCURRENCE.
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<br />NOTICE EFFECTIVE '10/01/02 IS ATTACHED TO AND
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<br />Al'yROVED AS TO FORM
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<br />IJeputy City Attorney'
<br />
<br />EMPLOYER
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<br />0'Z.. -03
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<br />, LEGAL NAME
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<br />MERCY f-ItiUSE TRANSITIONAL LIVING
<br />CENTERS
<br />PO BOX 1905
<br />SANTA ANA CA 92702
<br />
<br />MERCY HOUSE. TRANSITIONAL, LIVING CENTERS
<br />(A NON-PROFIT 'ORG,) (' ' :
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<br />THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND selF 10265 (REV 201)
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