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CERTHOLDER COPY <br />P.O. BOX 420807, SAN FRANCISCO,CA 94 1 42-060 7 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 10-06-2011 <br />CITYOF SANTA ANA SG <br />PUBLIC WORKS AGENCY <br />20 CIVIC CENTER PLZ <br />SANTA ANA CA 92701-4058 <br />GROUP: <br />POLICY NUMBER: 0802847-2011 <br />CERTIFICATE ID: 528 <br />CERTIFICATE EXPIRES: 10-01-2012 <br />10-01-2011/10-01-2012 <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 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 amand, 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, <br />and conditions, of such policy. <br />,e <br />Authorized Representative 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&GINDUSTRIES, INC. AND/OR CAIN, JAMES K. (AN <br />IND.) <br />7511 SUZI LN <br />WESTMINSTER CA 92683 <br />[GNC,CNI <br />PRINTED : 10-06-2011 <br />iREV.8-20101 <br />SG <br />