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CERTHOLDE~ r-0PY STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 COMPENSATION INSURANCE FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 07-01-2008 GROUP: POLICY NUMBER: 1638989-2008 CERTIFICATE ID: 84 CERTIFICATE EXPIRES: 07-01-2007 07-01-2008/07-01-2007 CITY OF SANTA ANA SC COMMINITY DEVELOPMENT AGENCY M-25 P 0 BOX 1988 SANTA ANA CA 92702 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 ~ 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. RIZED REPRESENTAT PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: ;1,000,000 PER OCCURRENCE. ENDORSEMENT ~f0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2005-07-01 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF SANTA ANA ENDORSEMENT X2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 07-01-2003 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER FEEDBACK FOUNDATION, FOUNDATION, INC 1200 N KNOLLMOOD CIR ANAHEIM CA 92801 INC DBA:FEEDBACK SC .... .. ~_ c f :iii'. SC M0408 IREV.2-05) PRINTED 06-19-2006 C . ~ - RECEIVED JUN 2 81~