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CERTHOLDER COPY <br />STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br />COMPENSATION <br />INSURANCE <br />FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 10-01-2007 GROUP: <br />POLICY NUMBER: 1209851-2007 <br />CERTIFICATE ID: 22 <br />CERTIFICATE EXPIRES: 10-01-2008 <br />10-01-2007/10-01-2008 <br />CITY OF SANTA ANA SP JOB -ALL OPERATIONS <br />COOMITY DEVELOPMENT AGENCY M-25 <br />P.O. Box 1988 <br />SANTA INA <br />CALIFORNIA 82702-1988 <br />This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the <br />Caliiorn a Insurance Commissioner to the employer named below for the policy period indicated. <br />This policy is not subfect to cancellation by the Fund except upon 30 days advance written notice to the employer. <br />We will also give You 30 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 />�THORIZEDREPRESENTATI PRESIDENT / <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 10-01-1997 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />THOMAS HOUSE TEMPORARY SHELTER (A NON-PROFIT <br />ORG.) <br />PO BOX 2737 <br />GARDEN GROVE CA 92842 <br />M0408 <br />(REV.2-05) <br />PRINTED : 09-17-2007 <br />SP <br />