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,! JUH '3 'Ct '6.43 FRObI; '-T34 P.04/J4 F-36' <br />CERTHOLDER COPY SC <br />~~T~ P.q, e0x 420F307, SAN FRANCISCO,CA 94142.-08Q7 ~ ~~ ~ J ~ ~ ~ <br />COMPRNIRATION <br />tNtSURAMCR <br />V N ~ GERTIFIGATE OF WORKERS' CONIPEN3/1TION INSURANCE <br />ISSUt: t~TE: 08-18-t;009 GRQUp: <br />POLICY NUMBER: 17S4Y01-2009 <br />CERTIFICATE ID: t <br />' CERTIFICAT6 EXPIRES: Ot4-Oi-2007 <br />OS-Ot-Z000/0{-01-2007 <br />CJTY OF SANTA ANA SC <br />soT. MAnrr sr~IRer <br />80 CIVIC CENTER PLZ <br />SANTA ANA CA DY701-4000 <br />Thia is to caftill' that we have Issued a vditS WOricere' Compenaatlon inaurance pogCy in a form approved oy the <br />Gautornla Insurance Gortmissloner tp hs emp;oyerr Waned below fa the poiloy po~~od indicted. <br />Thia poGtr i~ rat avb~eot to oenoeuatien by the Fund except upon 10 days acvance written nOtioe to tfle Bmpioyer, <br />We wil also give You tOtlays advance noilCe sttOUib th,e policy pI Can~ell•d prior to Ile normal ercp~ration. <br />Th,s cer;ihc~ta Ot insurance is not an iruuranca policy and does not amend, extend or sitar the coverage afforded <br />by the policy listed heroin. NatwithstiL~ding any reGUirernent. term or condition of arty contract or other document <br />w th rvsoect to which this CertlhCate of insurance may be ISfued or to which it may pertain, the ins~rarce. <br />afforded oy the policy described hereir, is suolOCt to all the terms, exciusions, and contlitions, of such poUcy. <br />~>~~i~ <br />"~FidRIZEO REPRESENTATI PRESIDENT <br />EMPLOYER'S LIMILITY LIMIT INCLUOINO DEFENSE COSTSt 11,000,000 PER OCCURRENCE. <br />ENDORSEMENT w00i5 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2007-08-13 IS <br />ATTACHED TO ANa FOR1i1S A PART OF THIS POLICY. NAME 0- ADDITIONAL. INSURED: <br />CITY OF SANTA ANA <br />ENDORSEMENT N1000 -DOUGLAS SHAW PRESIDENT - EXCLUDED. <br />ENDORSEMENT' N1600 - EMMA LET'ICIA tiMAM SECRETARY - EXCLUDED. <br />ENDORSfMEPLT rr1dt30 - MARIO U CARDENAS TREASURER - EXCLUDED. <br />ENDORSEMENT X1600 - MARCO A CARDENAS LsDARDMEM -EXCLUDED. <br />Ai PROVED AS TO FO:~~~~ <br />L,t a ,tilt Sl;>redy <br />EMPLOYER p,,,istant City Atwrr. ~' <br />CIVIC COLLECTION INC SC <br />168Li ELOERTREE OR <br />DIAMOND MAR G 1170'6 <br />(S' S,SC <br />iNEV.i•961 PRINTED 08-to-s~o7 <br />