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OEfisl34-2007(THU) 1629 RFP Insurance Rgency (FF?()1 31D 645 315D P. 002/003 <br />,. <br />CERTHOLDER CQPY <br />sc <br />~7 !I a~~ P.O. BOX 420807, SAN FRANCISCO,CA 94142-0907 <br />CQMPENSpTtON <br />i N S U R A H C E <br />~,,,,~ ~ ~ Cl~RTIF(CATE pF WORKERS' COMPENSATION INSt !RANGE <br />ISSUE dA't'E: Q9-27-2007 GFiQUP: 000667 <br />PODGY M1tUMOl:R oootoa7-3007 <br />GERTIFICATE IQ; 40 <br />CEgTIFICATE F~c~IRE;S:a7-o1-2008 <br />O7-Ot•200~/07-Oy-20O9 <br />CITY CLERK Of THE CITY OF COUNCIL SC <br />CITY OF SANTA ANA <br />20 CIViC CENTER PLZ N-30 <br />SANTA ANA CA 82701-4058 <br />This is to certify that we have Isxued a valid Workers' Cgmpensatign Insurance policy In a fprm approved by the <br />California Insurance Commissloner to the employer named below for the pulley period indicated. <br />This policy is not subject to cancellation by the Fund except upon 1o days advance K Bitten notice to the emploYer• <br />Wo wil! also give you 10 days advance notice should this policy be cancelled prior to its normal expiration. <br />This tart!#icate of insurance is not an insurance policy and does nqt amend. extend ar alter the cgvorage afforded <br />by ti-e Polley Ilsted heroin. Notwlthstandin any requirement, term or condition of any ~ :ontract or other doeumert <br />with respect to which this oertlficate of insurance may be issudd or to which it may iortaln, the insuranae <br />afforded by the policy described herein is subject to all the terms, exclusions, and cc idttions, of such pol{cy i <br />r^~~.~ '~ ~r r~ <br />MORiZED REPRESENTAT PRESIDENT r <br />EMPLOYER'S LIASILiTY LIMiT INCWDING DEF~1S8 GOS'1'S: St,000,000 P:ER OCCURRENCE. <br />ENDORSEMENT NODiS ENTITLED ADDITIONAL INSURED EMPLOYER EFFEGTIVE :!007-09-27 IS <br />ATTACHED YO ANb FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL I115URED: <br />CITY CLERK OF THE CITY OF COUNCIL <br />~~ <br />ENDORSEMENT N2570 ENTITLED WAIVER OF SUBROGATION EFFEC'CIVE 2007-O.i-27 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: <br />CITY CLERK OF THE CITY OF COUNCIL <br />i <br />EMPLOYER <br />ASSOCIATION FDR RETARDED CITIZENS ANo <br />MID-CITIES (A NON PROFIT CORD) <br />14208 TOMNE Avt <br />605 ANGELES CA 90081 <br />~`''~ ~ <br />C~~ ~~~~ <br />1 <br />`, ~ ~~~ ~~ <br />a\~`~' <br />i <br />sc <br />[l313,SC <br />Ittl;v.x-osr P ZIli'I'EO 08-27-2 07 <br />