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<br />BROKER COPY <br /> <br />SG <br /> <br />STATE <br />COMPENSATION <br />INSUPtANCE! <br />FUND <br /> <br />P.o. BOX 420807, SAN FRANCISCO,CA 94142-0B07 <br /> <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />N-2.001D-1'l.'Z. <br /> <br />GROUP: 000496 <br />POLICY NUMBER: 0004715-2005 <br />CERTIFICATE ID. 133 <br />CERTIFICATE EXPIRES: 01-01-2008 <br />01-01-2007/01-01-2008 <br /> <br />ISSUE DATE: 12-22-2006 <br /> <br />CITY OF SANTA ANA <br />MARID GHIZZI <br />20 CIVIC CENTER PLZ <br />SANTA ANA CA 92701-4058 <br /> <br />SG <br /> <br />Thi;. IS to certify that we have issued a valid Workers' CompensGtion ins.urtlnce policy in iI form approved by tns <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 upon30 days advance wriller! Jlotice to the employ@.r <br /> <br />We will also give you 30days advllnce notice should this policy be cancelled prior to its normal expiration. <br /> <br />This certificate of insurance is not an insurance policy OInd does nol i'lmend, extend or alter the coverage afforded <br />b'}i the policy listed, herein. Notwithstanding any requirement. term 01 condition of any contract or other document <br />With respect to which this certlflCi'lle 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 />THORIZED REPRESENT A TI <br /> <br /> <br />~ <br /> <br /> <br />PRESIDENT <br /> <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 P~R OCCURRENCE. <br /> <br />ENDORSEMENT #1600 - DAVID ORTIZ P,S,T - EXCLUDED. <br /> <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 01-01-2007 IS <br />------ATTACHED TO AND FORMS A PART OF THIS POLICY. <br /> <br />EMPLOYER <br /> <br />MESQUEMAI, INC DBA: OLYMPIQUE <br />CARE <br />26232 ENTERPRISE CT <br />LAKE FOREST CA S2630 <br /> <br />EXPERT BUILDING <br /> <br />/\= <br /> <br />._;- '-~_~ /,',; TO FORM <br /> <br />~~tt <br /> <br />; h.',~,':, ~,'t"~;icJ,CY <br /> <br />PRINTED <br /> <br />[B13,NBj <br />12-22-2006 <br /> <br />(REV.2-051 <br />