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<br />S'TATE
<br />CO......PENsA'rrON
<br />INSU~ANCE
<br />FUND
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<br />CERTIFICATE <~Fi WORKEFlS'COMPENSA TION)NSURANCE
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<br />ISSUE DATE: 10-01-02
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<br />POLICY NUMBER: . 1209902 - 02
<br />CERTIFICATE EXPIRES: 10-01-03
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<br />Cn(OF SANTA. A.NA.
<br />COMl'\UNTTV "DEVElOPMENLAGE~CYM-25
<br />POBOX. 1988 /' iA.TTN.';OHN,MAlONEY
<br />SANTA A.NA.CA ,92702, . 'h
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<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.
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<br />This policy is not subject to cancellation by the Fund except upon 30 days' ,ldvI'nee written' notice to the employer.
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<br />We will also give YO~39'da)"sf' aqva?CEI notice shouldthis _policy be cancelled prio'r to .;its -norrnalexpiration,
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<br />This certif'lcate'bf.fins'~(~rtc,~,_is,nCft_,~nirisurance,'policyand does not amend~ eXl~m1i'or'",,,lter__th~,p~yerage afforded
<br />by the pqlicjes listed hereip:,Nptwithstandir}QanY"f!3QU,ire.mfmt. term.orcoQditi_oF') Q,fany contract, or other docu~_enL<,
<br />with resp(i!:ct to which this certificate of insursnce,,.,,ay be "i~suedormay pertain.:-'the insurance afforded:by the ~
<br />policies de~ci-ibed herein is sUbject to all ~he t~rrns. excl~siqns ,and conditi~ns of ' such policies. t-
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<br />~isIDENT '..~,
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<br />EMPLOYER'S LIABILITY L'lMIT INCLUDING DEFENSE CDSTS: $1;000',000.00 PER,DCCURRENCE.
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<br />. ENOORSEMENT #2065 ~NTiTL"D CERTIFICATE HOLDERS'NOTICE EFFECTIVE '10/01/02 IS ATTACHED TO AND
<br />FORMS A PART OF THIS POLICY. " . \ '.' . "
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<br />Ai'l'ROVED AS TO FORM
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<br />L~~~heedY, ... ......
<br />Deputy City Attorney
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<br />EMP~OYER
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<br />OL..~o3
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<br />LEGAL NAME
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<br />MERCY'HOUSE TRANsITIONAL LIVING
<br />CENTERS . ;
<br />PO BOX 1905 . , ..
<br />SANTA ANA CA 92702
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<br />MERCY,HOUSE.TRANS;TIONAL LIVING CENTERS
<br />(I< NON-PRDFIT:ORG; )
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<br />THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND selF I026StREV 2",1)
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<br />'b9~i 8-02
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