HENNESSEY & HENNESSEY INC. 1A - 2006

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HENNESSEY & HENNESSEY LLC A-2006-046 REVIEWED BY EUNICE HEREDIA (PG 4 OF 5) CERTHOLDER COPY SIP CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 07-01-2015 CITY OF SANTA ANA SP PUBLIC WORKS AGENCY 20 CIVIC CENTER PLZ # M36 SANTA ANA CA 927011-4058 GROUP: POLICY NUMBER: 1354525-2015 CERTIFICATE: ID- 92 CERTIFICATE EXPIRES: 07-01-2016 07-01-2015/07-01-2016 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named beiow for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer, We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does, not amend, extend or alter the coverage afforded by the policy listed herein, Notwithstanding any requirement, term or condition of any contract or other docurnent with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,0017,000 PER OCCURRENCE. ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED; EMPLOYER EFFECTIVE 2014-07-01 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF SANTA ANA ENDORSEMENT #1901 - SHARON A HENNESSEY - EXCLUDED, ENDORSEMENT 02065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 07-01-2003 IS ATTACHED TO AND FORMS A PART OF THIS POLICY, EMPLOYER HENNESSEY & HENNESSEY LLC DBA: HENNESSEY & HENNESSEY LLC '17802 17TH ST STE 102 TUSTIN CA 92780 M0408 (REV .7- 20 141 PRINTED : 06-17-2015