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CERTHOLDER COPY STATE P.O. BOX 420807, SAN FRANCISCO,CA 94 i 42-0807 COMPENSATION INSURANCE FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 09-27-2007 GROUP: 000567 POLICY NUMBER: 0001087-2007 CERTIFICATE ID: 40 CERTIFICATE EXPIRES: 07-01-2008 07-01-2007/07-01-2008 CITY CLERK OF THE CITY OF COUNCIL SC ~ ~ ~ U07~O i O CITY OF SANTA ANA 20 CIVIC CENTER PLZ M-30 SANTA ANA CA 92701-4058 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 10 days advance written notice to the employer. We will also give you 10 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. THORIZED REPRESENTATI PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: 51,000,000 PER OCCURRENCE. ENDORSEMENT 110015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2007-09-27 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY CLERK OF THE CITY OF COUNCIL ENDORSEMENT X2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2007-09-27 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY CLERK OF THE CITY OF COUNCIL EMPLOYER ASSOCIATION FOR RETARDED CITIZENS AND MID-CITIES (A NON PROFIT CORP) 14208 TOWNE AVE LOS ANGELES CA 90061 f"' "'~ I"t7 -~ ;'1 t~ t .... ,::~ --~ ..~» C') ~" .. t" Z ~ SC sc [613,SC] IREV.2-05) PRINTED 09-27-2007