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<br />CERTIFICATE HOLDER COpy <br /> <br />......"'-' <br />STATE P.O. BOX 420807, SAN FRANCISCO. CA 94142-0807 <br />COMPI!NSATION <br />INSURANce <br /> <br />FUN 0 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />NOVEMBER 8, 2002 <br /> <br />GROUP: 000488 <br />POLICY NUMBER: 626-2001 <br />CERTIFICATE ID: 5 <br />CERTIFICATE EXPIRES: 02-01-2003 <br />02_01_2002/02-01-2003 <br /> <br />CITY OF SANTA ANA CDBG M-25 <br />COMMUNITY DEVELOPMENT AGENCY <br />P.O. BOX 1988 M-25 <br />SANTA ANA, CA 92702 <br /> <br />RE: FUNDING <br /> <br />This is to certify that we have issued a valid Worker's Compensation insurance policy in a form approved by the California <br />Insurance Commissioner to the employer named below for the policy period indicated. <br /> <br />This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. <br /> <br />We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. <br /> <br />This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the <br />policies listed herein. Notwithstanding any requirement, term or condition of any contract or other document with <br />respect to which this certificate of insurance may be issued or may pertain, the insurance afforded by the poiicies <br />described herein is subject to all the terms, exclusions, and conditions, of such policies. <br /> <br />~ <br /> <br /> <br />I(~", ~LJ'."- <br /> <br />PRESIDENT <br /> <br />AUTHORIZED REPRESENTATIVE <br /> <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE <br /> <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 02-01-2002 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br /> <br />EMPLOYER <br /> <br />TEAN CHALLENGE OF SO CA INC DBA: TEEN CHALLENGE OF <br />SO CA , INC <br />POBOX 5039 <br />RIVERSIDE CA 92517 <br />