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PDFLauncher ServIet <br />hays: //epfsfo. scif com/s erv I et/ PD FLauncherServ let <br />POLICYHOLDER COPY <br />P.0 . BOX 8152, PLEASANTON, CA 54688 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 12-12-2012 <br />CITY OF SANTA ANA. ATTN PURCHASING DEPT <br />20 CIVIC CENTER PL2 <br />SANTA ANA CA 92701-4058 <br />SP <br />GROUP <br />POLICY NUMBER: 9034897-2012 <br />CERTIFICATE - ID-. 3 <br />CERTIFICATE rXPIRE5: 08-01-$013 <br />11-21-2012108-01-20"13 <br />This is to certify that we have issued a valid Workers' Compensation insurance policy m a form approved by the <br />California Insurancm Ca+rnrr(ssioraer to the employer named below for the policy period indicated. <br />This poitey is not subject to cancellation by the Fund except upon 30 days advancer written notice to the employer. <br />We will also give you 30days advance notice should this policy oe "nestled prior to its normal expiration, <br />This certificate of insurance 1E net an insurance policy and does not attend, extend or altar the coverage afforded <br />by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other documetrc <br />with respect to which this certificate of insurance may be issued or to which it may pattern, the insurance <br />afforded by the policy dese'dsd herein is subject to all the Items, exclusions, <br />j` and conditions, of such poltcy. <br />Authorized Representativef President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT !#0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2012-12-12 Is <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSUREO; <br />CITY OF SANTA ANA ATTN PURCHASING DEPT <br />ENDORSEMENT #1000 - FINE, SHARON P,S T - EXCLUOED. <br />ENDORSEMENT #i206E ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 11-21-2012 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />- P-PROVED AS F( <br />?'VVL <br />Laura A. Rossini <br />Assistant City Attorney <br />EMPLOYER <br />U & R TOWING INC <br />3307 S MAIN ST <br />SANTA ANA CA 52707 <br />SP <br />[P10,SP] <br />I of I 3/25/2013 10:11 PM