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V <br />CERTHOLDER COPY <br />P.O. BOX 420807, SAN FRANCISCO,CA 94142 -0807 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 04 -14 -2012 <br />THE CITY OF SANTA ANA <br />1000 E SANTA ANA BLVD STE 200 <br />SANTA ANA CA 92701 -3900 <br />SP <br />V2- 1)2 -��' <br />GROUP. 000567 <br />POLICY NUMBER: 0000772 -2011 <br />CERTIFICATE 1D: 23 <br />CERTIFICATE EXPIRES: 04 -14 -2013 <br />04- 14- 2012/04 -14 -2013 <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 />►' tl/►� FA4fysl- <br />Authorized Representative President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT 112065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 04 -14 -2008 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />ORANGE COUNTY CHILDREN'S THERAPEUTC ARTS <br />2215 N BROADWAY <br />SANTA ANA CA 92706 <br />VNIQ <br />��SP ��ity At�.orn y <br />AsS�S,�ant <br />i� <br />SP <br />M0408 <br />PRINTED : 03 -17 -2012 <br />(REVS -2010) <br />SP <br />