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POLICYHOLDER COPY SG P.O. E30X 8192, PIEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 10-01-2013 CITY OF SANTA ANA SG PUBLIC WORKS DEPT 20 CIVIC CENTER PLZ SANTA ANA CA 92701-4068 45aOUP. PG'UCY NUMBER: 0802847-2013 CERTIFICATE ID: $72 CERFiFIGATE EXPOES: 10-01-2014 10-01-2013/10-01-2014 This is to certify that vie have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to oancenatlor by the Ford except upon 80 days advance written nonce to the amployer. We will also give you 30 days advance notice should this policy be cancelled prior t0 its r Ormai exotraaon. This csr=,ificafe of insurance is rot an ini policy and does not amend, extend or alter the Coverage afforded by the policy hwed herein. Notwithstanding anv reaulrement, term Cr COnditiOrt or anv Contract or othar document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afPorded by the poliov described herein is subject to all trio terms, oxclusions, and conditions, of such policv. Authonxed Representative President and GE0 EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: x$1,000,000 PER OCCURRENCE, ENDORSEMENT 90015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2012-10-01 TS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF SANTA ANA ENDORSEMENT #1600 - JAMES K. CAIN, PRESIDENT - EXCLUDED. ENDORSEMENT 92065 ENTITLED CERTIFICATE MOLDERS' NOTICE EFFECTIVE 10-01-1983 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ,,Jt=ara & Rossini EMPLOYER JuG INDUSTRIES, INC. AND/OR CAIN, JAMES K. (AN IND.) 7511 SUZI LN WESTMINSTER CA 92583 M0410 titEV.1-2otz) PRINTED : 09-17-2013