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Dec 10 2007 1:04PM <br />• i <br />714-685-1464 <br />CERTHOLDER COPY <br />P.6 <br />SG <br />STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br />COMPENSATION A _ ^O t'0 <br />/ <br />INSUR ANCI! �' [J <br />FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 12-10-2007 GROUP: <br />POLICY NLWBER: 1877734-2007 <br />CERTIFICATE ID: 1 <br />CERTIFICATE EXPIRES: 01-01-2008 <br />10-24-2007/01-01-2008 <br />CITY OF SANTA ANA <br />ATTN: CYNTHIA GOMEZ <br />20 CIVIC CENTER PLZ N-36 <br />SANTA ANA CA 82701-4058 <br />SG <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 that will expire or did <br />expire as Indicated above. <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 R may pertain, the insurance <br />afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. <br />tT111IZED REPOIR'E�SENTATZ]iPRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #1000 - THOMAS, ROBERT PRESIDENT TREASURER - EXCLUDED. <br />EMPLOYER <br />R V THOMAS INC. DBA: WEST COAST LAND CLEARING <br />PO BOX 8012E <br />LONG BEACH CA 90809 <br />(REV,2-DSI <br />i <br />[B15,NCI <br />PRINTED : 12-10-2007 <br />I <br />