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CERTHOLOER COPY <br />JJ W It. l..'aj{-oade P <br />--S <br />C- -r— <br />P.O. BOX 8192, PLEASANTON, CA 94588 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 04-14-2013 <br />THE CITY OF SANTA ANA <br />1000 E SANTA ANA BLVD STE 200 <br />SANTA ANA CA 92701-3900 <br />SP <br />GROUP: <br />POLICY NUMBER: 9048536-2013 <br />CERTIFICATE ID: 4 <br />CERTIFICATE EXPIRES: 04-14-2014 <br />04-14-2013/04-14-2014 <br />cr, --�6) <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 S0 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 />4W <br />Authorized Representative President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT A2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 04-14-2013 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 />APR Og 2013 <br />I'PSrk VED rs <br />TO FORV1 <br />" LISF. E. STO or <br />ey <br />Assistant City Attforn <br />SP 1// <br />M0408 <br />(REV.t-2012) PRINTED : 04-02-2013 <br />