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Sample Workers' Comp Form <br />STATE P.O. BOX 420607, SAN FRANCISCO. CA 94742 -0807 <br />CO NIP6 NSATtON <br />•NatUAANCfC <br />�U IV � CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />NOVEMBER Sr 1997 <br />POLICY NUMBER: 1 2 - 31 - 9 B <br />CERTIFICATE EXPIRES: <br />r <br />CITY OF SANTA ANA <br />INFORMATION SERVICES M -12 ATTN LYNDA KELLY <br />P O BOX 1388 <br />SANTA ANA CA 92702 JOB: VERIFICATION OF INSURANCE <br />L <br />This is to certify that wa have issued a valid Workers' Compensation insurance policy in a form approved by the California <br />Insurance Commissioner to the employer named below for [ha policy period Indicated. <br />This policy !s not subject to cancellation by the Fund except upon ten days' advance written notice to the employer. <br />Wa w{II 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 aRer the coverage afforded by the <br />poticies listed herein. Notwlthstanding any requirement, term, or condition of eny contract or other document wJlh <br />respect to which this certificate of Insurance may ba Issuem 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 />�k�' <br />AUTHORI2EO REPRESENTATIVE PREBIOaNT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: yIr 000. 000 PER OCCURRENCE <br />EMPLOYER <br />r <br />=,�. <br />THIS DOCUMENT Hf1S A QLUE PATTERNED BAC KGF70UND su1 w2e� (HEV � -psi <br />49 <br />