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VIIIVIAU14 V0,43 rAA <br />CERT •iOLDER COPY <br />10003/003 <br />SP <br />P.O. SOX 420807, SAN FRANCISCO,CA 94142-08:17 <br />CERTIFICATE OF WORKERS' COMPENSATION INSUR !kNCE <br />ISSUE DATE: 07-10-2012 <br />CITY OF SANTA ANA, ITS OFCRS & EES SP <br />BLDG INSPECTION DEPT <br />20 CIVIC CENTER PLZ <br />SANTA ANA CA 92701-4058 <br />GROUP: <br />POLICY NUMBER: 111152490-20112 <br />CERTIFICATE JD: 3 <br />CERTIFICATE EXPIRES: 04-011-20113 <br />06-01-2012/0:;-01-2013 <br />This is to certify that we have issued a valid Workers' Compensation insurance policy In a for •1 approved by the <br />California Insurance Commissioner to the employer named below for the policy period indicate.:, <br />This policy is not subject to cancellation by the Fund except upon 10 days advance written nc lice to the employer. <br />We will also give you 10 days advance notice should this policy be cancelled prior to its norn gal expiration. <br />This certificate of insurance is not an insurance policy and does not emend, extend or alter th:, coverage afforded <br />by the policy listed herein, Notwithstanding any requirement, term or condition of any contract ur ether document <br />with respect to which this certificate of insurance may be issued or to which It may pertain, 1-)e Insurance <br />afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. <br />%W .W. G <br />Authorized Representative President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCC.IRRENCE, <br />ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2012-0r-10 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: <br />CITY OF SANTA ANA, ITS OFCRS & EES <br />EMPLOYER <br />GRANDMA'S HOUSE OF MOPE SP <br />174 w. LINCOLN AVE. <br />ANAHEIM CA 92605 <br />IJMY,CSI <br />(REV.8-2010) PRINTED : 07-10-2012