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CERTHOLDER COPY <br />SP <br />P.O. BOX 8192, PLEASANTON, CA 94588 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 10-30-2014 <br />SANTA ANA POLICY DEPARTMENT <br />ATTN: TAYLOR GEIL-CHIEFS OFFICE M-97 <br />60 CIVIC CENTER PLZ <br />SANTA ANA CA 92701-4060 <br />SP <br />GROUP: <br />POLICY NUMBER: 0702761-2014 <br />CERTIFICATE ID: 38 <br />CERTIFICATE EXPIRES: 08-12-2015 <br />08-12-2014/08-12-2015 <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 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 />��..Y"^."'r' / u✓'� ''ic�v///cT..-�r.^ .)ren-«-�.., <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 2014-10-30 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: <br />SANTA ANA POLICY DEPARTMENT <br />ENDORSEMENT #1600 - NANCY K. BOHL PRES,SEC,TRES - EXCLUDED. <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 08-12-2011 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />NANCY K BOHL INC DBA: THE COUNSELING TEAM SP <br />INTERNATIONAL <br />1881 BUS CTR DR STE 11 <br />SAN BERNADINO CA 92408 <br />[PJP,CS[ <br />IREV.7-20141 PRINTED : 10-30-2014 <br />