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CERTHOLDER COPY <br />SQ <br />P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 03-22-2011 <br />CITY OF SANTA ANA SG <br />PO BOX 19e8 <br />SANTA ANA CA 92702-1988 <br />GROUP: 000092 <br />POLICY NUMBER: 0000878-20110 <br />CERTIFICATE ID: 370 <br />CERTIFICATE EXPIRES: 01-01-2012 <br />01-01-2011/01-01-2012 <br />THIS CERTIFICATE SUPERSEDES AND CORRECTS <br />CERTIFICATE # 340 DATED 01-04-2011 <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. Notwithstandlny 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 />Authorized Representative President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #1800 - ROGER FRANK PRES - EXCLUDED. <br />ENDORSEMENT #1800 - ALAN FRANK S,T - EXCLUDED. <br />ENDORSEMENT #2086 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 01-01-2008 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2011-01-04 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: <br />CITY OF SANTA ANA <br />EMPLOYER <br />JOHNSON-FRANK & ASSOCIATES (A CORP) SG <br />5150 E HUNTER AVE <br />ANAHEIM CA 92807 <br />API'ROVi to AS TO 1.0i: it, <br />..,aura Stitt slice <br />Assistant City AI >rr:. <br />[B1Q,SG1 <br />(REV.a•2010) PRINTED : 03-22-2011