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STATE COMPENSATION INSURANCE FUND - CERTHOLDER COPY e P.O. BOX 420807, SAN FRANCISCQ,CA 94142-0807 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 04-01-2006 GROUP: POLICY NUMBER: 0682897-2006 CERTIFICATE ID: 101 CERTIFICATE EXPIRES: 04-01-2007 04-01-2006/04-01-2007 CITY OF SANTA ANA COMMUNITY DEVELOPMENT AGENCY PO BOX 1988 SANTA ANA CA 92702 SP 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 below 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 document 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. a:::REPRESENTATI EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: ~ PRESIDENT $1,000,000 PER OCCURRENCE. ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2005-04-01 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF SANTA ANA ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 04-01-1993 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. APPRO' .JRM EMPLOYER ~~ 'Lau.ra AS::;Ista'.1t C,i; DAYLE Me INTOSH CENTER FOR THE DISABLED INC. #2 (A NON-PROFIT CORP.) DBA: DAYLE Me INTOSH CENTER 13272 GARDEN GROVE BLVD GARDEN GROVE CA 92843 (REV.2-05) PRINTED 03-18-2006 ~.~.~ SP M0408