Laserfiche WebLink
POLICYHOLDER COPY <br />P.O. BOX 420807, SAN 1=RANCISCO,CA 94142-0807 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 10-04-2009 <br />CITY OF SANTA ANA <br />20 CIVIC CENTER PL2 RM 429 <br />SANTA ANA CA 92701-4058 <br />GROUP: <br />POLICY NUMBER: 1? 14034-2009 <br />CERTIFICATE ID: 83 <br />CERTIFICATE EXPIRES: 10-04-2010 <br />10-04-2009/10-04-2010 <br />SP JOB:MANHOLE SPRAYING FOR ROACH CONTROL <br />This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the <br />Califiornia 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 ~ 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 />~~ ~~ <br />THORIZED REPRESENTATI PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT /{1600 - MURRILL ADAMS. PRESIDENT - EXCLUDED. <br />ENDORSEMENT !12065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 10-04-2003 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br /> <br />EMPLOYER <br />GOLDEN BELL PRODUCTS, INC <br />1200 N JEFFERSON ST STE M <br />ANAHEIM CA 92807 <br />SP <br />V E~~ ~~ ~~ ~pa~M <br />APpgO <br />__-- _~~- <br />- """weedy <br />Laut~~Stitt Sh <br />Assistant City Actornc) <br />SP <br />M0410 <br />(REV.2-o5- PRINTED 09-17-2009 <br />