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<br />POLICYHOLDER COPY <br /> <br />SG <br /> <br />STATE <br />COMPENSATION <br />INSUFtANCE <br />FUND <br /> <br />P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br /> <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />ISSUE DATE: 06-19-2007 <br /> <br />GROUP: 000290 <br />POLICY NUMBER: 0002003-2007 <br />CERTIFICATE 10: 11 <br />CERTIFICATE EXPIRES: 04-01-2009 <br />04-01-2007/04-01-2008 <br /> <br />CITY OF SANTA ANA <br />CARLA MACK-THDMPKINS <br />PO BOX 1988 <br />SANTA ANA CA 92702-1988 <br /> <br />SG <br /> <br />This is to certify that we have issued ;a valid Workers' Compensation insurance policy in iiI form approved by the <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 upon 30 days advance written notice to the employer. <br /> <br />We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. <br /> <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. Notwjthstandin~ 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 /> <br />=-REPRESENTATI <br />EMPLDYER'S LIABILITY LIMIT <br /> <br /> <br />~ <br /> <br />PRESIDENT <br />INCLUDING DEFENSE COSTS: $l,ooO,Doo PER OCCURRENCE. <br /> <br />ENDDRSEMENT #1600 - WHITECOTTDN, ROBERT P,S T - EXCLUDED. <br /> <br />ENDDRSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 05-29-2007 IS <br />------ATTACHED TO AND FORMS A PART DF THIS POLICY, <br /> <br />EMPLOYER <br /> <br />APrROV bu AS TO FORM <br /> <br /> <br />~LCdY <br />A').:>lstaL1t ,,--~ity Attor..ey <br /> <br />MASTER LANDSCAPE & MAINTENANCE, INC. SG <br />10171 NORTHAMPTDN AVE <br />WESTMINSTER CA 92683 <br /> <br />PRINTED <br /> <br />[B1E.SP] <br />06-19-2007 <br /> <br />lREV.2-05) <br />