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<br />CERTHOLDER COPY <br /> <br />STATE <br />COMPENSATION <br />INSURANCE <br />FUND <br /> <br />P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br /> <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />ISSUE DATE: 10-01-2007 <br /> <br />GROUP: <br />POLICY NUMBER: 1209851-2007 <br />CERTIFICATE 10: 22 <br />CERTIFICATE EXPIRES: 10-01-2008 <br />10-01-2007/10-01-2008 <br /> <br />CITY OF SANTA AHA <br />CQIiIUlIITY OEVELOPMENT AGENCY "-28 <br />P.O. lOX 11.. <br />SANTA ANA <br />CALIFORNIA '2702-1'" <br /> <br />SP <br /> <br />\JOB: ALL OPERATIONS <br /> <br />Trl1s IS to certify tNit we N1ve Issued a valid Workers' Compensation insurance poltCY In a form approved by the <br />Call1orn'i Insurance CommISSioner to the employer named below for the policy period indicated. <br /> <br />ThIS POliCY IS nol subject to cancellation by the Fund except upon 30 days advance written notice to the employer. <br /> <br />We Will also gl\le 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 amend. extend or alter the coverage afforded <br />b~ 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 />C1:::-REPRESENTATI <br /> <br />EMPLOYER'S LIABILITY LIMIT <br /> <br /> <br />~{:~~- <br /> <br />PRESIDENT <br /> <br />INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br /> <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 10-01-1997 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br /> <br />EMPLOYER <br /> <br />THOMAS HOUSE TEMPORARY SHELTER (A NON-PROFIT <br />ORG. ) <br />PO BOX 2737 <br />GARDEN GROVE CA 92842 <br /> <br />(REV.2-05) <br /> <br />PRINTED 09-17-2007 <br /> <br />SP <br /> <br />M0408 <br />