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CERTHOLDER COPY <br />SO <br />STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br />COMPENSATION <br />INSURANCE <br />FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 08-11-2007 GROUP: <br />POLICY NUMBER: 1553216-2006 <br />CERTIFICATE ID: 178 <br />CERTIFICATE EXPIRES: 08-01-2007 <br />08-01-2006/08-01-2007 <br />CITY OF SANTA ANA so JOB:JEROME PARK CARNIVAL <br />DATES: JUNE 27 - JULY 2, 2007 <br />888 W SANTA ANA BLVD STE 200 <br />SANTA ANA CA 92701-4581 <br />This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the <br />California Insurance Commissioner to the employer named below for the policy period indicated. <br />This policy is not subject to cancellation by the Fund except upon30 days advance written notice to the employer. <br />We will also give you 30days advance notice should this policy be cancelled prior to its normal expiration. <br />This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded <br />by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document <br />with respect to which this certificate 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 />�V r <br />THORIZED REPRESENTATI PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT M1800 - RALPH CHRISTIANSEN PRESIDENT - EXCLUDED. <br />ENDORSEMENT X1600 - BARBARA CHRISTIANSEN SEC TRES - EXCLUDED. <br />ENDORSEMENT N1600 - TOM BROWN VICE PRESIDENT - EXCLUDED. <br />ENDORSEMENT k1600 - WILLIAM JACOB VICE PRESIDENT - EXCLUDED. <br />ENDORSEMENT N2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 08-01-2003 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />CHRISTIANSEN AMUSEMENTS, INC <br />PO BOX 997 <br />ESCONDIDO CA 92033 <br />IREV.2-051 <br />AiIROVIl '4 "„ <br />so <br />As�la W�.� .,ay �iiiUil;Cy <br />IB18,SDj <br />PRINTED : 08-11-2007 <br />