Laserfiche WebLink
APPENDIX D Sample Insurance Forms <br />(Concluded) <br />somata worKers~ coma rorm <br />STATE PO ROX 420807, SAN FRANCISCO, CA 941420807 <br />COMPENSATION <br />INSURANCE <br />FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />NOVEMBER Sr 626-97 UNIT 0000116 <br />1997 <br /> POUCV NUMBER: <br />1 2- 31 - 9 8 <br /> CERTIFICATE E%PIRES: <br />r <br />CITY OP SANTA ANA <br />INFORMATION SERVICES M-12 ATTN LYNDA KELLY <br />P 0 80% 1988 <br />SANTA ANA CA 92702 JOB: VERIPICATION OF INSURANCE <br />L <br />This is to certify [hat we have issued a valid Workers' Compensation insurance policy in a form approvetl by the California <br />Insurance Commissioner to the employer nametl below for the policy periotl intlicatetl. <br />This policy is not subject to cancellation by the Fund except upon [en days' aWance written notice to the employer. <br />We will alsc give you TEN days' advance notice should this policy be cancelled prior to its normal expiration. <br />This certificate of insurance is not an insurance policy and tlces not amend, extend or after [he coverage afforded by the <br />polices fated herein. Notwithstanding any requirement, term, or condition of any contract or other document with <br />respect to which this certificate of insurance may be issuetl or may pertain, [he insurance afforded by the policies <br />describetl herein is subject [o all the farms, exclusions antl contli[ions o(such policies. <br />gUTHORIZED REPR ESENTP.TIVE PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: ~1r 000, 000 PER OCCURRENCE <br />EMPLOYER <br />r <br />APR CONSULTING INC <br />22632 GOLDEN SPRINGS STE 380 <br />DIAMOND BAR CA 91765 <br />,~.. <br />Page 33 of 34 <br />