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POLICYHOLDER COPY SK <br />STATE <br />P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br />COMPENSATION <br />INSURANCE <br />r U N D <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 02-07-2009 <br />GROUP: 000238 <br />POLICY NUMBER 0005845-2008 <br />CERTIFICATE ID: 35 <br />CERTIFICATE EXPIRES: 02-07-2010 <br />02-07-2009/02-07-2010 <br />CITY OF SANTA ANA SK <br />PURCHASING <br />20 CIVIC CENTER PLZ PMB 1988 <br />SANTA ANA CA 92701-4058 <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 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 />HORIZED REPRESENTATI TT PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #1600 - JONES, EARL DOYLE.-PRESIDENT TREASURER - EXCLUDED. <br />ENDORSEMENT #1600 - JONES, CHARLEEN WREY, SECRETARY - EXCLUDED. <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 02-07-2009 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />PACIFIC SYSTEMS ELECTRIC, INC SK <br />32870 DOWLING DR <br />WINCHESTER CA 92596 <br />M0410 <br />IREV.Y•051 <br />PRINTED : 01-16-2009 <br />AppRO v to AS TO FORM <br />Laura Stitt Sheedy <br />Assistant City Attorney <br />