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POLICYHOLDER COPY <br />NE <br />CO If11 C <br />COMPENSATION P.O. BOX 8192, PLEASANTON, CA 94588 <br />INSURANCE <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 10 -01 -2012 <br />CITY OF SANTA ANA NE <br />FRANK HERNANDEZ - DEVELOPMENT AGENCY M -25 <br />20 CIVIC CENTER PLZ <br />SANTA ANA CA 92701 -4058 <br />GROUP: 000488 <br />POLICY NUMBER: 0001566 -2012 <br />CERTIFICATE ID: 10 <br />CERTIFICATE EXPIRES: 10 -01 -2013 <br />10 -01- 2012/10 -01 -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 />• t -e�,4� . 4w_ <br />Authorized Representative President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT H2O65 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 10 -01 -2010 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />gPPRO <br />VED AS TO FORM <br />LISA ORCK <br />Assistant City Attorney <br />EMPLOYER <br />• THOMAS HOUSE TEMPORARY SHELTER (NON- PROFIT <br />ORG.) DBA: THOMAS HOUSE TEMPORARY SHELTER <br />PO BOX 2737 <br />GARDEN GROVE CA 92842 <br />[RMM,CN) <br />(REV.1 -2012) PRINTED : 10 -02 -2012 <br />