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<br />STATE <br />COMPENSATION <br />INSURANCE <br />FUND <br /> <br />N - dool-OO~ <br />fJ - dO 0-7 - O&>) <br /> <br />IN REPLY REFER TO: <br /> <br />NOVEMBER 28, 2007 <br /> <br />CITY OF SANTA ANA <br />CLERK OF THE CITY COUNCIL <br />20 CIVIC CENTER PLZ M-30 <br />SANTA ANA CA 92701-4058 <br /> <br />CERTIFICATE OF WORKERS' <br /> <br />----------------------- <br /> <br />COMPENSATION INSURANCE <br /> <br />---------------------- <br /> <br />CANCELLATION/CONVERSION NOTICE <br /> <br />------------------------------ <br /> <br />RE: CERTIFICATE DATED DECEMBER 1, 2007 <br /> <br />THE WORKERS' COMPENSATION COVERAGE PROVIDED UNDER THE <br /> <br />POLICY LISTED BELOW IS BEING CONVERTED TO A NEW POLICY <br /> <br />EFFECTIVE DECEMBER 1, 2007. THE NEW POLICY WILL PROVIDE <br /> <br />UNINTERRUPTED COVERAGE. <br /> <br />YOU WILL RECEIVE A NEW CERTIFICATE OF INSURANCE UNDER <br />THE NEW POLICY NUMBER: 562-0001885-07. <br /> <br />IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT THE CUSTOMER <br /> <br />SERVICE CENTER AT THE NUMBER LISTED BELOW. <br /> <br />EMPLOYER: <br /> <br />MANAGEMENT PARTNERS, INC <br />1730 MADISON RD <br />CINCINNATI, OH 45206 <br />POLICY 1414076-07 <br /> <br />CUSTOMER SERVICE REPRESENTATIVE <br />CUSTOMER SERVICE CENTER <br />(877) 405-4545 <br /> <br />1275 Market Street . San Francisco. CA 94103-1410 <br />Mailing Addros", P.O. Box 420807 . San Francisco, CA 94142-0807 <br /> <br />selF 19102 <br />