Laserfiche WebLink
CERTHOLDER COPY <br />STATE P.O. BOX 420607, SAN FRANCISCO,CA 94142-0807 <br />COMPENSATION <br />I N S U R A N C E <br />FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 10-14-2008 GROUP: 000567 <br />POLICY NUMBER: 000 1 08 7-2008 <br />CERTIFICATE ID: 51 <br />CERTIFICATE EXPIRES: 07-01-2009 <br />07-01-2008/07-01-2009 <br />CLERK OF THE CITY COUNCIL SC <br />CITY OF SANTA ANA <br />20 CIVIC CENTER PLZ M-30 <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 />THORIZED REPRESENTATI PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE C05TS: 51,000,000 PER OCCURRENCE. <br />ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2008-i0-14 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: <br />CLERK OF THE CITY COUNCIL <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 10-14-2008 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2008-10-14 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: <br />CLERK OF THE CITY COUNCIL <br />EMPLOYER <br />ASSOCIATION FOR RETARDED CITIZENS AND SC <br />MID-CITIES (A NON PROFIT CORP) <br />14208 TOWNE AVE <br />LOS ANGELES CA 90061 <br />~~~~~~ ~;n tiS Tn FORM <br />t.~~ :`_. <br />~55i5taut ~.:~ly Alwrney, <br />IB13,SCj <br />SC <br />(REV.2-051 PRINTED 10-14-2008 <br />