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Mar 05 2007 9:42AM APOLLO SOUTH <br />714-685-1464 <br />STATESATPOLICYHOLDER COPY <br />P.O. BOX 420807, SAN FRANCISCO,CA 94 1 4 2-080 7 <br />INSURRAN <br />COMPENSATION <br />NSCE <br />FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 03-05-2007 <br />GROUP: 000046 <br />POLICY NUMBER: 0013446-4007 <br />CERTIFICATE ID. 36 <br />CERTIFICATE EXPIRES: 01-01-2008 <br />01-01-2007/01-01-2008 <br />CITY OF SANTA ANA <br />PUBLIC WORKS AGENCY SG <br />PO BOX lose <br />SANTA ANA CA 82702-1889 <br />ATTN: CINDY i <br />CThialifos is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the <br />rnia Insurance Commissioner to the employer named below for the policy period indicated. <br />This policy is not subject to cancellation by the Fund exceot upOn30 days advance written notice to the employer. <br />We will also give you 30 days advance notice should this policy be cancelled prior to 'ts normal ecpiration. <br />This certificate of insurance is not an insurance policy and does not amend, extend or a',ter the coverage afforded <br />b�ilhy the policy listed herein Notwithstanding any requirement, term or condition of <br />afforded <br />respect to which this described <br />of insurance may bte issued or to vvhich it aMAY contract or ether document <br />of larded by the policy describetl herein is subject to all the terms, exclusions, and conditions the insurance <br />nce <br />1 <br />policy. <br />vY <br />t,`DR�,,E, REPRESENTATI <br />PRESIDENT <br />EMPLOYER'S LIA8ILITY LIMIT INCLUDING DEFENSE COSTS: 51,000,000 PER OCCURRENCE. <br />ENDORSEMENT X1500 - DAVID RANDOLPH THOMAS PRESIDENT - EXCLUDED. <br />ENDORSEMENT X1600 - ROBERT VICTOR THOMAS VICE PRESIDENT SECRE - EXCLUDED. <br />ENDORSEMENT ftO65 ENTITLED CERTIFICATE HOLDERS' EFFECTIVE 01-01-2007 IS NOTICE <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />D THOMAS CORP DBA: WEST COAST LAND CLEARING <br />PO BOX 80126 <br />LONG BEACH CA 80605 <br />IHEV.2-051 <br />PRINTED : O35[815,NCI <br />2007 <br />P.6 <br />Se <br />