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1~5115121~g9 15:12 5652662 WORK CENTER F'A(aE t=t'2
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<br />CERTIFICATE O~ WC~IFtKER$' COMPENSATION COVERAGE p
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<br />PROOUCeR THIS CERTIFICATE IS ISSUED AS MATTER OF INFORMATION ONLY
<br /> AND CONFERS NO RICWT3 UPON THE CERtIFlCATE HOLfJER.
<br />NonArQfits' United Workers' C.orrTpen~ Lion Croup THIS CERTIFICATE ODES NOT AANENC, ExTEND OR ALTER THE
<br />344 Thomas t... i3cerklcy Way, Su itr 340 COVERAGE AFFORDED BY TWE POLL[ IES BELOw_
<br />Oakland. CA 94b12
<br />hhonc: (877) 551-6717 INSURERS AFFORDING COVERAGE
<br />Fax: f 53()} Z74-987 i
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<br />INSURER INSURERA: NOrlProfitC' l.lnitccl VVOrkc rs' Compensation Group
<br />Orange Coun#y GQnservatlon Co~I:)s INSUR~i s: ACE IJSA
<br />1853 North Raymond Avenue
<br />Anaheim, CA 928tl1-1717 INSUaaR r,;
<br /> iNSURF_R D:
<br /> INSURER E:
<br />COVERAGES This Certifica#a ig noi. IntendE d to s(:ecify ali endorsements , coverage, #erms, condllbns and exdusions of the ollcies shown,
<br />TWE PQI,ICIES OF COVERAGE l15TED BELCIW I-IAVI BEEN SSUED TO THE AFFILIAT E MF_MAFR NAMEb ABdVE FOR'TWF_ PQI,IC,Y PFRI00 INDICATED. NOTWITI45TANDING
<br />ANY RC-QUIRF_MFNT, TERM, OR CONDITICd'd OF AN`. GONTFIACT OR OTHER DOCUMENT WITW RF,$PECT TO WHICH THIS CERTIFICATE 14gY RE ISSUED OR MAY PERTAIN. THF_
<br />COVERAGE AFFORDEb BY TFIE POI-ICI&i~> DESCF !BED W =REIN IS SUBJECT TO ALL TWE TERMS, EXCLU31ON5 AND CONDITIONS OF : •IJGH POLICIES. AGGREGATE LIMITS
<br />SHOWN MAY HAVE BEEN REDUCED BY Pu Ij CLAIM i.
<br />IL7R TYPE OF COVERAGE
<br />,,,,, IbLICY IVUM9IER POLICY
<br />EFFECTNE DATE POLICY
<br />EXPIgATION DATE LIMIT3
<br />GENERAL LIABILITY CACI•I OCCURRENCE $
<br />CpMMFRCIAC GENCRAL LIABlli,i'Y FIRE gAMA .E (Any one fire) $
<br />CWMSMAbC: 9CC.UR MEDC)(PENSE(Anytxlepere0n) $
<br />G@NERAL AOdREGiATE LIMIT APPll~lt$ + ~/1 PK,RSgNAL i ADV INJURV
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<br />POLICY PROJECT LOC Q ~~y(~~
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<br />GENERALA~GRE(~A7F
<br />••, p, F*O PRODUCTS-COMP/OP AGG $
<br />AUTOMOBILE LMBILn'Y CpMi31NF-A •iINGLE llMir $
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<br />(BPCh acdde,tl $
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<br />ALL owNED AUT08
<br />.., t..k~t} C •7 BODILY INJURY
<br />ACNF
<br />OULED AUTOS ~ a•
<br />, (Per person) $
<br />WIRED AUT03
<br />NpN-0WNCDAUT03 _ - (P6raccklnnt, ~
<br />•, PROP6RTYi~AMAGE $
<br />-.,` (Pat arridanl ,~
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<br />WORKf=RB' COMPEN$ATI01'~I WC STAT OTHER
<br />LIMITS x
<br />A ANC1 ~ NPC-wc:c, nn1-2009 1!1109 I/1/10 E. L.£ACWAr;CIDENT $ ~pp~ppp
<br />EMPLOYI"RS LIABILITY
<br /> GL. OISFA$P: - EA EMPLOYL•E $ 50Q,~QQ
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<br />..~- E.I-, 171REASf: -COVERAGE LIMIT $ ~~~~~
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<br />DESCRIPTION OF OPERATIONSILOCATH„}NSlVEI ICLES
<br />l:?(CLUSION3
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<br />OBD B Y ENOORSEAgENT/SPECIAIJPIROVISiON9
<br />F..vidoncc of Wnrkcrs' C'ompe:nsation ~I:'overa{ v:
<br />CERTIFICATE HOLDER a?AITIONAI IN8uRIiA; INSUREfi LETTER: CANCI;: I,1,A,TiUEV
<br />Npuwt,G-cK'CC-U41 SHOUf,p ANY OF TWE ABOvE DESCRIBED POLICIES BE CANCELLED
<br /> 9EFORE THE EXPIRATION DATE THF_REOF, THE ISSUING INSURER WILL
<br /> ENDE4VOR TO MAIL 30 DAYS WRfTTEN NOTICE TO THE: CERTIFICATE
<br />City of-San#s Ana HOLbER NAMED TO THE LEFT, SUT FAILURE TO DO SO $HgLL IMPOSE
<br />
<br />Workforce [nvestmcnt Board NO OBLIGATION OR Li,4BILITY OF ANY KIND UPON THE INSURER, 1T$
<br /> AGENTS OR REPRESENTATIVES
<br />
<br />A, O, Box 14RR M-73 .
<br />Santa Ana, CA 927(12 AUTHQRIZED REPRESENTArivE
<br />
<br />Based orw ACORD 25-$ (7197)
<br />
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