CIVIC COLLECTIONS INC. 4C - 2008

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CErTHOLDER COPY SC P.O. BOX 420807, SAN FRANCISCO,CA 94142 -0807 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 05 -03 -2010 CITY OF SANTA ANA SC BLDG INSPECTION DEPT 20 CIVIC CENTER PLZ SANTA ANA CA 92701 -4058 GROUP: POLICY NUMBER: 1784604 -2009 CERTIFICATE ID: 4 CERTIFICATE EXPIRES: 08 -01 -2010 08- 01- 2009/08 -01 -2010 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer. We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. t Representative Interim President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2010 -05 -03 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF SANTA ANA ENDORSEMENT #1600 - DOUGLAS SHAW PRESIDENT - EXCLUDED. ENDORSEMENT #1600 - EMMA LETICIA SHAW SECRETARY - EXCLUDED. ENDORSEMENT #1600 - MARIO J CARDENAS TREASURER - EXCLUDED. ENDORSEMENT #1600 - MARCO A CARDENAS BOARDMEM - EXCLUDED. EMPLOYER CIVIC COLLECTIONS INC SC 1565 ELDERTREE DR DIAMOND BAR CA 91765 [B13,SCj PRINTED : 05 -03 -2010 (REV. 1 -20 10)