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CERTHOLDER COPY <br />P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 12-01-2010 GROUP: <br />POLICY NUMBER: 167 92201 <br />CERTIFICATE ID: L_ <br />O� a CERTIFICATE EXPIRES: 12- 74011 '- <br />12-01-2010/12-CZ9'3?1]11 sa- <br />CITY OF SANTA ANA SP C) <br />60 CIVIC CENTER PLZ <br />SANTA ANA CA 92701-4060 <br />r� W <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, <br />and conditions, of such policy. <br />4�11 <br />t � w7 E4, <br />Authorized Representative6 President and CEO <br />UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING: <br />THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER; <br />EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING <br />CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS' <br />COMPENSATION LAW. <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />API-' ') I ORNI <br />- MELD Vii. :c» I I I%%'AITE <br />APPROVED AS TCP FORM <br />EMPLOYER ; �17 <br />MELISSA M. ATE <br />GRUVER, ERIC PH D Deputy City Attqawey <br />17772 17TH ST STE 106 <br />TUSTIN CA 92780 <br />M0408 <br />(REV.8-2010) PRINTED 11-17-2010 <br />SP <br />