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ON <br />GROUP: <br />POLICY NUNIBER: 13345213-2014 <br />CER7FICATE ID: 92 <br />CERTIFICATE EXPIRES: 07-01-2015 <br />07-011-20114/07-01-2015 <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 after 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 fs subJect to air the terms, exclusions, and conditions, of such policy, <br />Authorized Representative President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT •#0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2014-07-01 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY, NAME OF ADDITIONAL INSURED: <br />CITY OF SANTA ANA <br />ENDORSEMENT #1901 - SHARON A HENNESSEY - EXCLUDED, <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 07-01-2003 it <br />ATTACHED TO AND FORMS A PART OF THIS POLICY, <br />EiMPLOYER <br />AEiTNESSEY & HENNESSEY LLC DBA� HENNESSEY & <br />HENNESSEY LLC <br />17602 17TH ST STE 102 <br />TUSTIN CA 92780 <br />iREV. 1-20 1 Z <br />� J o -s'e- <br />FORM <br />t City Attorney <br />M0408 <br />waa,�� <br />HENNESSEY & FIENNESSEY, 1. LC AGR# X2006-04-6 & A-2014-035 (FIG, 5 of 5) <br />RE <br />