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STATE <br />COMPENSATION <br />IN S U R A N C E <br />FUND <br />CIVIC CENTER BARRIO HOUSING CORP. <br />98o w 17TH ST STE E <br />SANTA ANA CA 92706 <br />Dear Policyholder, <br />AUG 0 6 1001 <br />JULY 30, �Q7 <br />.r . asa°raSW r <br />Policy 1167483 <br />Your workers' compensation insurance policy will soon renew <br />with State Fund. Enclosed is a list of certificates of insurance that <br />were issued on your policy during the past policy year. <br />These certificates will expire on the policy renewal date. <br />Please take a moment to review the enclosed list and <br />verify the accuracy of addresses, legal names, endorsements, etc. <br />To ensure these certificates are issued appropriately, upon the renewal <br />of your policy, please request changes as follows: <br />1. Note either "Yes" or "No" in the Automated Renewal column. If <br />no change to the renewal status is necessary for a particular <br />certificate, no additional notation is required. <br />2. Waivers of Subrogation do not automatically rollover. If a waiver is <br />required, please indicate by writing "WAIVER" next to the certholder's <br />name. <br />3. Note requests for other endorsements next to each certificate listed. <br />The above will help ensure that certificates required upon the renewal <br />of your policy are issued as requested. In addition, it will <br />prevent the issuance of certificates that are no longer necessary. <br />In order to change the status of these certificates, please return the <br />amended list to State Fund no later than August 30, 2007. <br />If State Fund does not receive the amended list by this date, all <br />certificates will automatically be produced as listed. Lists that <br />have no changes or notations need not be returned. <br />Please fax the amended list to (866) 266 -2071. To avoid delays, please be <br />certain to use the above fax number or the mailing address on the enclosed <br />envelope. <br />Should you have any questions, please contact us at (877) 405 -4545. <br />Thank you, <br />Customer Service Department <br />Customer Service Center <br />Enclosures <br />Southern California Customer Service Center <br />Mailing Address: P.O. Box 92503 ■ Los Angeles, CA 90009 -2503 <br />1167483S <br />