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POLICYHOLDER COPY <br />STi~TE P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br />COMPENSATION <br />INSURANCE <br />U N ~ CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 02-01-2009 GROUP: <br />POLICY NUMBER: 1886779-2009 <br />CERTIFICATE ID: 4 <br />CERTIFICATE EXPIRES: 02-01-2010 <br />02-01-2009/02-01-2010 <br />CITY OF SANTA ANA SG <br />DEPARTMENT OF PUBLIC WORKS <br />220 S DAISY AVE <br />SANTA ANA CA 92703-4334. <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 Fund except upon 10 days advance written notice to the employer. <br />We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration. <br />This certificate of insurance is not an insurance policy and does not amend, 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 />THORIZED REPRESENTATI <br />~~ `~~ <br />PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />APPROVEll AS TO PQRM <br />Laura Stitt Shee <br />Assistant City A orney <br />EMPLOYER <br />CLINICAL LABORATORIES OF SAN BERN AND/OR GEO <br />MONITOR INC <br />PO BOX 329 <br />SAN BERNARDINO CA 92402 <br />SG <br />M0409 <br />IRev.z-o5> PRINTED 01-16-2009 <br />