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<br />J~'. <br /> <br />2007 12:36PM <br /> <br />949-631-8439 <br /> <br />p.2 <br /> <br />.--- <br /> <br />POL.ICYHOLDER COpy <br /> <br />IQ <br /> <br />STATJ5' . <br />e:aM...NSATI N <br />INSUJltA... . <br />I=U N C ClRTIP'ICATE OF WORKERS'COMPENSATlON INSURANCE <br /> <br />%S1U1! DATI: 1_21_1001 . GROUP: <br />,- POliCY NUMElI!~ 1482711-2008 <br />i CeRTlPICATE 10: B <br />CERTIFICATE EXPIRi51 10-0t-lI007 <br />10.01-aooe/10-o1~2007 <br /> <br />P,O. BOX. 420B07, SAN FRANCISCO.CA 94142,-0807 <br /> <br />: -:"'\" <br />10 . .~,.:: . <br />..~~ <br />~.-; <br />. . .{ <br /> <br />, <br /> <br /> <br /> <br />CITY at' UNJ'I ANA <br />CO.....ITY I:II~ILDIIMI!NT AGINCY <br />plQ ~x .... . . <br />1 NNT~ ANA CA 11701-,... <br /> <br />SIiI <br /> <br />lJO.:ALL OPIRAUONI <br /> <br />Thl. II to r:tIl1If INII WI hIv. ''''''If I valid Wcix...,' Comp.nutlon 1"lUr~ pollc:y In . form 8PProved by the <br />Gln'or",. In.~ . CDl'M'lI..lon... to Ill. .mpfoyw named blilCIW' 'or 1he Policy p.rlod lncficlbld. <br /> <br /> <br />ThI, 1:Ia/loy I, <br /> <br />_Jeel 'CO Ilancelletlon II)' th. Fund _0. uponlO d.yt IClvancl/ wrltt.n 'loUce tel tn. .mp1ovur. <br /> <br />YOU 80 d..,. MlV8nc. notlGl -"aul" ~hl. pOnD!' D' oancetl4ld prior to 11:. norm.1 .x~r'llon. <br /> <br />Thlt c.rtlf~.t, Jf 1na&I1l1cl. II not.. 1rt.Ul'*"C' pollcy a'ld cIo.. not am."d, 'ld.nd ar lie.. the O'OVII'Ill' ,trora~ <br />by 1M PCIIIr:y IlI1ed t.reIn. NotwfthlUodlno any '"-lI-tlr.mont. tll'm or condition Qf any contrKlt ()I' otller dca,,",I'it. <br />wl1h r'IPtot to ifvt1ici1 1tI.. wll,1ci1e Of ItI.LlI'.ll~. /NY b. 1.11l~ or to which it nwy p.r~ln. the Intunr.cl <br />"1~d,d bv tt1t pr;ll~ dncrlb.d hlr.ln I. .lilIJeot tc .11 tM I. I'M" ')(clu.lo"., and condit/ens, of -.Jch ~oUcy, <br /> <br /> <br /> <br />a:::f_~ <br /> <br />~ <br /> <br />PRESIDeNt <br />IiIllPI.OYI.'. LfAlILZTV I.ZM:T INC;LUQIIC DtP'INSE caSTS: $ t ,000, 000 PIR ~CUARINC:!. <br />INDO.SINENT 100,. INT%TLED ADDZTIONAL INlURlD EMPLOY." I"ICTIYE 1001-10-01 IS <br />ATTACfoUrD TO P 'D_I 4 "".T or nal POLICY, NAIf! OP ADDITIONAL nc"up: <br />CITY OF SANT ANA . <br />- <br />: IICOIWIM8NT '208& INTITI.ID CERTI'ICATI ttr:JL.DElRI' NOTICE IPPICTIVE 10-01-2008 11 <br />; ATTACHID T-o D 'aul A PART 0' THZS PUI.:rev. <br /> <br />- <br /> <br />- <br /> <br />i <br /> <br />EMPL!oVER <br />! <br /> <br /> <br />'laMIN HrLPU. WOlttN (A NCIN..,.RafIT "tJaLrc <br />llNEFIT COItP.') <br />711 W 17TH i~ ITE A10 <br />. <<:DITA MilA CiJ ..117 <br /> <br />SII <br /> <br />(II!V.20011 <br /> <br />PRINTED <br /> <br />(JRQ.SC] <br />011-211-1008 <br /> <br />