Laserfiche WebLink
Sample WorKers' Comp Form <br />STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142 -0807 <br />COMPENSATION <br />I N S U Rw A ■ N C E <br />U • Y � CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />NOVEMBER 5, 1997 <br />POLICY NUMBER: 1 2 - 31 - 9 8 <br />CERTIFICATE EXPIRES: <br />r <br />CITY OF SANTA ANA <br />INFORMATION SERVICES M -12 ATTN LYNDA KELLY <br />P O BOX 1968 <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 [he California <br />Insurance Commissioner to the employer named below for the policy period indicated. <br />This policy is no[ subject to cancellation by the Fund except upon tan days' advance written 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 requirem en[, 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 [he terms, exclusions and conditions of such policies. <br />��-�- � � <br />a� <br />AU TH ORIZEO REPRESENTATIVE PR ESIpENT <br />EMPLOYER'S LIABILITY LIM ZT INCLUDING DEFENSE COSTS: �lrOOOr 000 PER OCCURRENCE <br />EMPLOYER <br />r <br />_� <br />THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND scar �oaev IgEV. � -as> <br />48 <br />