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POLICYHOLDER COPY SG <br />P.O. BOX 8192, PLEASANTON, CA 94588 <br />ISSUE DATE: 10-01-2013 <br />CITY OF SANTA ANA SO <br />PUBLIC WORKS DEPT <br />20 CIVIC CENTER PLZ <br />SANTA ANA CA 92701-4058 <br />GROUP: <br />POLICY NUMBER: 0802849-2013 <br />CERTIFICATE ID: 572 <br />CERTIFICATE EXPIRES: 10-01-2014 <br />10-01-2013/10-01-2014 <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 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 />Authorized Representative President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #0095 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2012-10-01 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED; <br />CITY OF SANTA ANA <br />ENDORSEMENT #4800 - 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 />I <br />EMPLOYER <br />J&G INDUSTRIES, INC. AND/OR CAIN, JAMES K. (AN <br />IND.) <br />7511 SUZI LN <br />WESTMINSTER CA 92883 <br />A. Rossini <br />"9y Attorney <br />M0410 <br />(RE V,1-2!112) PRINTED : 09-17-2013 <br />