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<br />CERTHoLoER COPY <br /> <br />STATE <br />COMPENSATION <br />INSURANCE <br />FUND <br /> <br />P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br /> <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />ISSUE DATE: 04-01-2007 <br /> <br />GROUP: <br />POLICY NUMBER: 0682897-2007 <br />CERTIFICATE 10: 101 <br />CERTIFICATE EXPIRES: 04-01-2008 <br />04-01-2007/04-01-2008 <br /> <br />CITY OF SANTA ANA <br />COMMUNITY DEVELOPMENT AGENCY <br />PO 80X 1988 <br />SANTA ANA CA 92702 <br /> <br />A~ d-f)Dlf2 - oq).._ DJtf <br /> <br />SP <br /> <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 /> <br />This policy is not sUbject to cancellation by the Fund except upon 30 days advance written notice to the employer. <br /> <br />We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. <br /> <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 it may pertain. the insurance <br />afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. <br /> <br />6::"-REPRESENTATI <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: <br /> <br /> <br />~ <br /> <br />PRESIDENT <br />$1,000.000 PER OCCURRENCE. <br /> <br />ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2005-04-01 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: <br />CITY OF SANTA ANA <br /> <br />ENDORSEMENT #2085 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 04-01-1993 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br /> <br />A~~;7"")n{'~-.' .,', ", <br />. -.;.. .i',~ ~ j" : "1 j.. TI~,'''''. j"~"~ <br />-.. "" < -4-.J:...J '"..., i t.~.. "l.;:-~ <br /> <br />~;v'1 <br /> <br />EMPLOYER <br /> <br />._~ <br /> <br />LaL;ro >:/ 'l-I"~:-,=Jj---"- <br />AS.,lsta,H Ciiy Al~ur'-iCY <br /> <br />DAYLE Me INToSH CENTER FOR THE DISABLED INC. <br />#2 (A NON-PROFIT CORP.) o8A: DAYLE Me INToSH <br />CENTER <br />13272 GARDEN GROVE BLVD <br />GARDEN GROVE CA 92843 <br /> <br />jREV.2~05) <br /> <br />PRINTED <br /> <br />03-16-2007 <br /> <br />SP <br /> <br />M0408 <br />