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APPENDIX D Sample Insurance Forms <br />(Concluded) <br />,ample WOrKerSi' Vomp rorm <br />STATE P.O. BOX 420807, SAN FRANCISCO, CA 941420807 <br />COMPENSATION <br />INSURANCE <br />FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />NOVEMBER 5, 1997 POLICYNUMBER: 626 -97 UNIT 0000116 <br />CERTIFICATE EXPIRES: <br />F <br />CITY OF SANTA ANA <br />INFORMATION SERVICES M -12 ATTN LYNDA KELLY <br />P 0 BOX 1988 <br />SANTA ANA CA 92702 JOB: VERIFICATION OF INSURANCE <br />L <br />This Is to certify that we have issued a valid Workers' Compensation Insurance policy in a form approved by the California <br />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 ten days' advance written notice to the employer. <br />We will also give you TEN 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 by the <br />policies listed herein. Notwithstanding any requirement. term, or condition of any contract or other document with <br />respect to which this certificate of insurance may be issued or may pertain, the Insurance afforded by the policies <br />described herein is subject �to� all the terms, exclusions and conditions of such policies. /� Q <br />AUTHORIZEO REPRESENTATIVE PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: 41,000,000 PER OCCURRENCE. <br />EMPLOYER <br />I— <br />APR CONSULTING INC <br />22632 GOLDEN SPRINGS STE 388 <br />DIAMOND BAR CA 91765 <br />Page 35 of 36 <br />