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POLICYHOLDER COPY <br />SP <br />RO, BOX 5192, PLEASANTON, CA 94568 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE GATE: OS -04 -2014 <br />CITY OF SANTA ANA SP <br />20 CIVIC CENTER PLZ <br />SANTA ANA CA 92701 -4058 <br />GROUP: <br />POLICY NUMBER: 1731330 -2014 <br />CERTIFICATE ID; 12 <br />CERTIFICATE EXPIRES: 04 -01 -2016 <br />04 -01- 2014/04 -01 -2016 <br />This is to certify that we have Issued a valid Workers' Compensation Insurance policy In a farm 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 t0 days advance written notice to the employer. <br />We will also give you 10days 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 />Authorized Representative President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2014 -08 -04 Is <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: <br />CITY OF SANTA ANA <br />—� ENDORSEMENT #1600 - HOUTAN REZAEI PST - EXCLUDED, <br />EMPLOYER <br />NOGALIS INC. SP <br />4540 CAMPUS DR #151 <br />NEWPORT 8EACH CA 92560 <br />[P1F,SPj <br />IREV.1 -2x121 PRINTED : 08 -04 -2014 <br />