CIVIC COLLECTIONS, INC. 4A - 2008

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CERTHOLDER COPY STATE 42 — , P.O. BOX 420807, SAN FRANCISCOCA 941 COMPENSATION 0807 INSURANCE FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 08 -18 -2009 GROUP: POLICY NUMBER: 1794804 -2008 CERTIFICATE ID: 3 CERTIFICATE EXPIRES: 08 -01 -2009 08 -01- 2008/08 -01 -2009 CITY OF SANTA ANA SGT. MARTY SHIREY SC 60 CIVIC CENTER PLZ RM 97 SANTA ANA CA 92701 -4080 This is to certify that we have issued a valid Workers' Cornperlsation insurance Policy in a form a pproved by the Calitornia Insurance Commissioner to the employer ; amed below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer. We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. tTHORIZED REPRESENTATI J EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2009 -06 -16 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF SANTA ANA C-) ENDORSEMENT #1600 - DOUGLAS SHAW PRESIDENT - EXCLUDED. ~� ENDORSEMENT #1600 - EMMA LETICIA SHAW SECRETARY - EXCLUDED. ENDORSEMENT #1600 - MARIO d CARDENAS TREASURER EXCLUDED `^ - . � ENDORSEMENT u45oo - M�, N _ CARDE!d,",S E^.S,:Dl�ER7 - EXCLi;D =C. 3 W APPROVED AS TO FORM EMPLOYER Laura Stitt Sheedy Assistgilt (itv Attnrnev CIVIC COLLECTION INC 33875 OLD TRAIL DR YUCAIPA CA 92399 (REV.2 -05) SC [B13,SC[ PRINTED : 06 -16 -2009 SC