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CERTHOLDER COPY SP <br />ti <br />STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br />COMPENSATION <br />INSURANCE <br />FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 07-01-2009 GROUP: <br />POLICY NUMBER: 1354526-2009 <br />CERTIFICATE ID: 50 <br />CERTIFICATE EXPIRES: 07-01-2010 <br />07-01-2009/07-01-2010 <br />CITY OF SANTA ANA SP <br />PUBLIC WORKS AGENCY <br />20 CIVIC CENTER PLZ M36 <br />SANTA ANA CA 92701-4058 <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. <br />This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. <br />We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. <br />This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded <br />by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document <br />with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance <br />afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. <br />tTHORIZED REPRESENTATI PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #1901 - JOSEPH A HENNESSEY - EXCLUDED. <br />ENDORSEMENT #1901 - SHARON A HENNESSEY - EXCLUDED. <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 07-01-2003 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />HENNESSEY & HENNESSEY, LLC (A LIMITED SP <br />LIABILITY COMPANY) <br />17300 17TH ST # J-251 <br />TUSTIN CA 92780 <br />M0408 <br />(REv.2-05) PRINTED : 06-16-2009 <br />