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CERTHOLDER COpy SP STATE COMPENSATION INSURANCE I=UND P.O. BOX 420807, SAN FRANCISCQ,CA 94142-0807 CERTIFICATE OF WORKERS'COMPENSATION INSURANCE ISSUE DATE: 06-01-2007 GROUP: 000723 POLICY NUMBER: 0000075-2007 CERTIFICATE ID: 2 CERTIFICATE EXPIRES: 06-01-2008 06-01-2007/06-01-2008 CITY OF SANTA ANA COMMUNITY DEVELOPMENT AGENCY PO BOX 1988 M-25 SANTA ANA CA 92702 SP 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 30 days advance written notice to the employer. We will also give you 30 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. d:::"REPRESENTATI EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: ~ PRESIDENT $1,000,000 PER OCCURRENCE. ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2004-06-01 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF SANTA ANA ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLOERS' NOTICE EFFECTIVE 06-01-2005 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER BOYS AND GIRLS CLUB OF SANTA ANA (A NON PROFIT CORPORATION) 1615 E. 17TH STREET, SUITE 150 SANTA ANA CA 92705 (REV.2-05) PRINTED 05-17-2007 M0408