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CERTHOLDER COPY <br />STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br />COMPENSATION <br />INSURANCE <br />FUN D CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 08-03-2008 GROUP: <br />POLICY NUMBER: 1784604-2007 <br />CERTIFICATE ID: 2 <br />CERTIFICATE EXPIRES: 08-01-2008 <br />08-01-2007/08-01-2008 <br />CITY OF SANTA ANA SC <br />SGT. MARTY SHIREY <br />60 CIVIC CENTER PLZ <br />SANTA ANA CA 92701-4060 <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 Pund except upon 10 days advance written notice to the employer. <br />We will also give you 10 days :dvanca notice should this pollcy be cancelled prior to ita normal expiration. <br />This certificate of insurance is not an Insurance pollcy and does not amend, extend or altar the coverage afforded <br />by the pollcy listed herein. Notwlthstandln~ any requirement, term or condition of any contract or other document <br />with respect to which this certificate of nsurance may be Issued or to which ft may pertain, the Insurance <br />afforded bV the policy described herein is'sub]eet to all the terms, exclusions, and conditions, of such policy. <br />THORIZED REPRESENTATI PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />AT~TACHEDETO ANDIFORMSIALPARTDOFTTHISLPOLICYEDNAMELOFEA DITIONALEINSUREO•-03 IS <br />CITY OF SANTA ANA <br />ENDORSEMENT M1800 - DOUGLAS SHAW PRESIDENT - EXCLUDED. <br />ENDORSEMENT 41600 - EMMA LETICIA SHAW SECRETARY - EXCLUDED. <br />ENDORSEMENT A1800 - MARIO J CARDENAS TREASURER - EXCLUDED. <br />ENDORSEMENT giB00 - MARCO A CARDENAS BOARDMEM - EXCLUDED. <br />s'(j ~~?. <br />i.q r <br />%', <br />EMPLOYER <br />CIVIC COLLECTION INC SC <br />33875 DLD TRAIL DR <br />YUCAIPA CA 82389 <br />[B13,SC] <br />sc <br />PRINTED OB-03-2008 <br />wt v.a•osl <br />