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CERTHOLDER COPY <br />Sc <br />P.O. BOX 420807, SAN FRANCISCO,CA 94142 -0807 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 08 -01 -2011 <br />CITY OF SANTA ANA SC <br />SGT KOZAKPWSKI <br />20 CIVIC CENTER PLZ <br />SANTA ANA CA 92701 -4058 <br />GROUP: <br />POLICY NUMBER: 1794604-2011 <br />CERTIFICATE ID: 7 <br />CERTIFICATE EXPIRES: 08 -01 -2012 <br />08 -01- 2011/08 -01 -2012 <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 indicater.. <br />This policy is not subject to cancellation by the Fund except upon 10 days advance written nc,ice to the employer. <br />We will also give you 10 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 />tAut"h.,,,.d�Representative President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCJRRENCE <br />ENDORSEMENT #1600 - DOUGLAS SHAW PRESIDENT - EXCLUDED. <br />ENDORSEMENT #1600 - EMMA LETICIA SHAW SECRETARY - EXCLUDED. <br />ENDORSEMENT #1600 - MARIO 0 CARDENAS TREASURER - EXCLUDED. <br />ENDOR Iii N T - <br />S iL,v, n�iUV4 Irj,yKCG H 6,ARGLIVia$ DGHKLINICirI — EXCLUDED. <br />APPRON ED %S TO hORNI <br />EMPLOYER <br />nt t� \ttut'uc� <br />CIVIC COLLECTIONS INC SC <br />1565 ELDERTREE DR <br />DIAMOND BAR CA 91765 <br />[B13,SCj <br />(REV.8-2010) PRINTED : 06 -07 -2011 <br />