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<br />" <br /> <br />CERTHOLDER COpy <br /> <br />STATE <br />COMPENSATION <br />INSURANCE <br />I=UNO <br /> <br />P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br /> <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />ISSUE DATE: 04-01-2007 <br /> <br />GROUP: <br />POLICY NUMBER: 1354937-2007 <br />CERTIFICATE ID: 39 <br />CERTIFICATE EXPIRES: 04-01-2008 <br />04-01-2007/04-01-2008 <br /> <br />CITY OF SANTA AHA <br />COMMUNITY DEVELOPMENT <br />20 CIVIC CENTER PLAZA <br />SANTA ANA CA 92702 <br /> <br />SP <br /> <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 /> <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 ilmend, extend or alter the coverage afforded <br />by the policy listed herein. Notwithstanding 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 />6:::-REPRESENTATI <br /> <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: <br /> <br /> <br />~ <br /> <br />PRESIDENT <br /> <br />$1,000,000 PER OCCURRENCE. <br /> <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 04-01-2003 IS <br />ATTACHED TO AHD FORMS A PART OF THIS POLICY. <br /> <br />/':_ _'- "./ ~~ /;..S T(Q FORM <br /> <br />~ <br /> <br />--.-.-- <br />~J.:.:r[t. Sf '.~~ S:...,....:Jj <br /> <br />EMPLOYER <br /> <br />.l'~h'lSt9 ~lt City At~cr:J.ey <br /> <br />ORANGE COUNTY ASSOCIATION FOR MENTAL HEALTH <br />822 W TOWN AHD COUNTRY RD <br />ORANGE CA 92868 <br /> <br />(REV.2-05) <br /> <br />PRINTED <br /> <br />03-16-2007 <br /> <br />SP <br /> <br />M0408 <br />