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1^;-'10/'2010 M:04 <br />#4450 P.006/008 <br />COPY <br />P Q BOX 420807, SAN FRANCISCO,CA 941 <br />CEMFICAT'B OF WORM W COMPONSATION MMOAM <br />tSSNE BATE: 1E-OY-2010 GRIM P. 000467 <br />POLICY NULMFb 00170U-2000 <br />CIStTIFIf..AM U>; 3139 <br />CSKnFICATE EXP 02-41-40111 <br />04-41-401 OQ-21-2011 <br />CITY OF 5M1t'A ANA <br />20 CtvzC Cam PLZ <br />SANTA ANA G 04701-40M <br />so <br />This Is to certify :hat we haw lssued a VOO Workers COmpentetfon insurame Mary In # arm approved by the <br />Capfarnis lnswwm Conrr>issioner to the employer nand below for fin poffcy period Ind! <br />This Polley is note )ad to camepetlan by the Fund except ;,pan 41) days *&.Wm written sodm to the san00yer. <br />We will also diva you 80 days advance notice should thls Poiley be c amelled prior to ft •dxplratiam <br />This csertiffph of irwnwe Is not an Wwxm o popsy and does not amend, extend or Ater tM covergs afforded <br />by the policy listsd herein Notwt ark requirwnelrt,twM of condition of any con t or other 4aoument <br />with repeat to which Chit esetif i1r>rroo MW b! issued Or t0 which it may the irourwwm <br />afforded by the policy. described herein is "Ject to ap the terms excksions, and of Koh paltry. <br />Authorised R.presentatlva PrAlook-exi CEO :-.7: <br />CIpLOYMS LIABILITY LIMIT MMUM M DEFENSE COSTS: *1.00O,OOQ PER w9unp <br />. <br />MM 00016 ENTITLED ADDITIONAL ZNSUOMD M UYRR EFFECTIVE 201 0-011 12 <br />ATTAf.M TO AMI FORS A PART OF TMS POLICY, NAME OF ADDITIONAL Y D: <br />CITY OF SANTA ANA <br />BMWRSEMRMT f1A00. - larm TERRA VICE PRESIOW !il:CRBTART - EigCLUDED, <br />ENDDRSEMW #IWO - WAFF, VAMES A PMI0W TWWRER EXC1.1pMED. <br />ENOORSENEW #4065 ENTITLED CERTIFICATE iNOLDERRI MMM OFFUTIV! 0e-0 -20110 IS <br />ATTAOM TO AM FOIFa116 A PART OF THIS POLICY. <br />ZMPLOYER <br />:...... • . -_APPROVE;`v,. AS TO F ]21V1 .. _... <br />-Assistant City At.tJr-ne <br />PWI! Ott"L & ELECTTtIC; lCAtC AND/OR DIXIE SC. <br />031"1. MWAN -f+iftaoly0 Mme" Cfl1 ZINC <br />41169 RD <br />EL MN'1'i: CA $1na. _ <br />te11,F3CJ <br />? : +s-ai?toto <br />SC