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POLICYHOLDER COPY <br />P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 02-10-2011 <br />CITY OF SANTA ANA PURCHASING SK <br />20 CIVIC CENTER PLZ PMB 1088 <br />SANTA ANA CA 92701-4058 <br />GROUP: 000238 <br />POLICY NUMBER: 0005845-2010 <br />CERTIFICATE ID: 124 <br />CERTIFICATE EXPIRES: 02-07-2012 <br />02-07-2011/02-07-2012 <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 after the coverage afforded <br />by the policy listed herein. Notwithstanding any requirement, terra 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 />Authorized Representative President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2011-02-10 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: <br />CITY OF SANTA ANA PURCHASING <br />ENDORSEMENT #1600 - JONES, EARL DOYLE PRESIDENT TREASURER - EXCLUDED. <br />ENDORSEMENT #1600 - JONES, CHARLEEN WREY SECRETARY - EXCLUDED. <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 02-07-2009 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />APP <br />EMPLOYER �sisiz:.S 1. tty ;" iiu ric <br />PACIFIC SYSTEMS ELECTRIC, INC SK <br />32670 DOWLING DR <br />WINCHESTER CA 92596 <br />IP17.SIQ <br />PRINTED : 02-10-2011 <br />(REV.8-2010) <br />SK <br />