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E~ <br />FROM :DIXIE DIESEL nn ELECTRIC FAX NO. :5626954800 Oct. O1 217178 02:32PM P4 <br />. ' ~ CERTHQLDER CQPY <br />~~~~~ P.O. BOX 120807, SAIV FF~gMClS~Cb,CA 84~ 1420807 , <br />Gi~MhCNSIpTIQ1N <br />INt?RUI9ANCf1R i ' <br />C~p71FICA'~ flL~ WORKE~tB' C~MP'BNBATION l~I~Ut~bNC~ ' <br />ISSUE GATE: 07-08^g0~78 ! I GROUP: <br />, ~ ~ POLICY fVUAA»~f~ i77714S-ZODd <br />CER7lFIG'iATly ~ gyp; sa f <br />CERtIpICATE EXPIRES: t#S-gi-sGpR <br />02-~y-200*/p~^Z1-2000 <br />i ~ I , <br />CITY QF SANTA ANIA. ! SSG <br />90 CIVIe CEPRSR PLY ~ ' <br />SANTA ANA CA 9270-088 <br />~ . I' ~ <br />I <br />i i~ <br />Thit ig t0 certify that wo hays Ip~ued a villlt! VYorkor~' GtimPmttsatian Insurance policy In a ferrr~ eysproved ~y the <br />CaNfornla Ingw~pnGp Cdrrtmlpgiarlar.tta '.thejornploYcr nsmod, below fnr the policy perlotl Indlt:atttd: <br />Thl$ policy It hot aub)ect -to canpellation~ by the Fund ~ox4tlpt up~A'S~' dpy~ edvanc® wr(tt9n not(cg td the dmp(Qy~r. <br />We will alsp 91ve you 3d days advance rlloties Should thls olic <br />P Y ba canoslled prior tp itg normal expfratlgR, <br />This certifi}cato of ingufanaa la not arc in ~urihbe <br />~Y the ~q pollcY and does not end, extend or •iter tft~, avvar,0a ~ffordpd~ <br />Ppect tloatwhic~h r~is~ csrttlflc~at Ainfi any requirement, term 'ar oondhion t?f +e-V;OOntracC 0r other document <br />with re:s nauranna mrAy be 1~laued pr to which It ma ertaln, <br />afforded by tna pal}py described herein i subjaCt to ail Y P the Irtsyr~gil <br />~e terrnw, axaltialona, aynd t:pnditfoi~s, of sueh pgllcv~ <br />THOftIZEp REPRE$~jTATI <br />pAESIDENT <br />EMPLOYER'S LsABILxTY LIMI'1f YINC AINf# DEPLNSp C.DST~i: *1,000,;0t)0 1PER o~1RRENCf3, ~ <br />ENDORSEMENT ~01t5 E111i'ITLEp A[iD .! AL IN$IJI~LO EMP~.QNpR,EFFECTxt{Ri7tp4r~-{'!7''-~$ i5 ' <br />AtTACHED TO ANp FORMS A PAFC7".0 TF1~5 P's1aLxCY: NAMLr OF pDDYTIONAL ~NSUR~D: <br />CITY D~ SANTA ANp, , <br />E1+fOORSEMEN'T iriQbp ~ iJAtdE$ 'SKgF ilP, ~ T .^ EXCLLIOEO. <br />ENDORSEMENT rV26BS'EI!r•TITLEq ~R E',ICATE F>SILDER$' NOTICE Et+t+EC'1'tVE ,0Z_si-sOp6 IS <br />ATTACHED TO AND FC~ltlr$ A PAiRt ; pp 'THYS POLYCY: <br />' ~ i <br />EMAL01'ER <br />b;<lLIE b3l~SEL !tt E"LEG~i'R~C, YNC <br />'WF'12STTlER~A 8 60LVH~ STE E <br />I <br />i <br />V.9~061 i <br />b0I~0 ~~d ~ i <br />I <br />Sc <br />l~~I~HO <br />5G <br />i, <br />1 ' ~~ ~ '. <br />~ ~. <br />G <br />I <br />[B10.SLj ~, <br />PRINTIib t)7-06~20~8 ' <br />~'e1,6s~~'~.6b-5bB ~i:si e0ea~serte <br />