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ISSUE DATE: 10-01-2010 <br />CITY OF SANTA ANA <br />PUBLIC WORKS AGENCY <br />20 CIVIC CENTER PLZ M-36 <br />SANTA ANA CA 92701-4058 <br />POLICYHOLDER COPY <br />P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />GROUP: <br />POLICY NUMBER: 0802847-2010 <br />CERTIFICATE ID: 419 <br />CERTIFICATE EXPIRES: 10-01-2011 <br />10-01-2010/10-01-2011 <br />SG JOB:ALL CALIFORNIA SITES <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 />4�'—-� ouc-� V.�Vt <br />tth,r,zed Representative Interim President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #1600 - JAMES K. CAIN, PRESIDENT - EXCLUDED. <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 10-01-1993 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />J & G INDUSTRIES, INC <br />(AN IND.) <br />7511 SUZI LN <br />WESTMINSTER CA 92683 <br />AND/OR CAIN, JAMES K. <br />��r-as..Pi1 Tc' <br />,4ssistallc City 1ttrr;c <br />MO410 <br />(REV.1-2010) PRINTED : 09-17-2010 <br />SG <br />