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A•20tu•0-15 <br />CERTHOLDER COPY <br />P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 03-16-2011 <br />CITY OF SANTA ANA SG <br />DEPARTMENT OF PUBLIC WORKS <br />220 S DAISY AVE <br />SANTA ANA CA 92703-4334 <br />GROUP: <br />POLICY NUMBER: 1886779-2011 <br />CERTIFICATE ID: 59 ! <br />CERTIFICATE EXPIRES: 02-01-2012 <br />02-01-2011/02-01-2012 <br />M, <br />W <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 />t ' `9awltr L <br />ARepresentative President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT 111600 - MELINDA FURNAS PRIES - EXCLUDED. <br />ENDORSEMENT #1600 - STEVE FURNAS SEC,TREAS - EXCLUDED. <br />ENDORSEMENT 112065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 02-01-2011 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />CLINICAL LABORATORIES OF SAN BERN AND/OR GEO <br />MONITOR INC <br />PO BOX 329 <br />SAN BERNARDINO CA 92402 <br />APp,RO VED <br />AS TO FORM <br />I ura Stitt Seed <br />ss1staut City Attr <br />ney <br />[B10,NK1 <br />1?- <br />SG <br />taev.8-20101 PRINTED : 03-16-2011