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CERTHOLDER COPY <br />P.O. BOX 8192, PLEASANTON, CA 94588 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 09 -01 -2014 <br />COMMUNITY DEVELOPMENT AGENCY SG <br />ADMINISTRATIVE SERVICES DIVISION M -25 <br />20 CIVIC CENTER PLZ <br />SANTA ANA CA 92701 -4058 <br />GROUP <br />POLICY NUMBER: 9023428 -2014 <br />CERTIFICATE ID; 9 <br />CERTIFICATE EXPIRES: 09 -01 -2015 <br />09- 01- 2014/09 -01 -2015 <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 30 days advance written notice to the employer. <br />We will also give you 80 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 />Authorized Representative President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1.000.000 PER OCCURRENCE. <br />ENDORSEMENT X2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 09 -01 -2012 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />PEOPLE FOR IRVINE COMMUNITY HEALTH (A SG <br />NON- PROFIT CORP.) DBA: 2 -1 -1 ORANGE COUNTY <br />1505 E 17TH ST STE 108 <br />SANTA ANA CA 92705 <br />M0408 <br />IREV.7 -20141 PRINTED : 08 -15 -2014 <br />SG <br />