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A foil-lG'�SP <br />CERTHOLDER COPY <br />P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br />FUND <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />GROUP: 000687 <br />ISSUE DATE: 04-14-2012 POLICY NUMBER: 0003772-2911 <br />CERTIFICATE 1D: <br />CERTIFICATE -EXPIRES: 2/04-14-2013 <br />THE CITY OF SANTA ANA <br />SP <br />1000 E SANTA ANA BLVD. STE 200 <br />SANTA ANA CA 92701-3900 <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 />Pon S0 days advance written notice to the employer. <br />This policy is not subject to Cancellation by the Fund except u <br />We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. <br />This certificate istedinsurance <br />he ©n° not an insurance policy and <br />Notwithstanding any requirement, doesnot <br />or conditi, extend or alter the on of any contract orcothergdocumenta <br />by the policy g <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 />14mol 4and CEO <br />Authorized Representative <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT <br />#2065 ENTITLED <br />CERTIFICATE HOLDERS' NOTICE EFFECTIVE 04-14-2009 IS <br />ATTACHEDFORMS <br />NS 10 TOO <br />eROK <br />G SP � CttY A�tOrney <br />ASStStaDt <br />f/ <br />EMPLOYER <br />ORANGE COUNTY CHILDREN'S THERAPEUTC ARTS SP <br />2216 N BROADWAY <br />SANTA ANA CA 92706 <br />PRINTED : 03-17-2012 <br />iREV.8-20101 <br />bf0408 <br />