Laserfiche WebLink
Sample Workers' Comp Form <br />STATE P.O. BOX 420807, SAN FRANCISCO, CA 941424)807 <br />COMPENSATION <br />INSURANCta <br />FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />NOVEMBER S, 1997 POLICY NUMBER: <br />CERTWICATE EXPIRES: 12-31-98 <br />r <br />CITY OF SANTA ANA <br />INFORMATION SERVICES N-12 ATTN LYNDA KELLY <br />P O BOx 1988 <br />SANTA ANA CA 92702 JOB: VERIFICATION OF INSURANCE <br />L <br />This Is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California <br />insurance Commissioner to the employer named below for the policy period indicated. _ <br />This policy Is not subject to cancellation bythe Fund 9=" upon ten days' advance WnIW notice to the employer. <br />We will also 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 does not amend, extend or alter the coverage afforded by the <br />policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document with <br />respect to which this Certificate of insurance may be issued or may pertain. the insurance afforded by the policies <br />described herein is subject to all the terms, exclusions and conditions of such policies. <br />AUTHORIZED REPREEENtATIVE PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: 41,000,000 PER OCCURRENCE <br />EMPLOYER <br />r <br /> <br />49 <br />25A-59