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POLICYHOLDER COPY <br />SP <br />P.O. BOX 8192, PLEASANTON, CA 94588 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 12-17-2014 <br />CITY OF SANTA ANA SP <br />20 CIVIC CENTER PLZ <br />SANTA ANA CA 92701-4058 <br />GROUP: <br />POLICY NUMBER: 9008463-2014 <br />CERTIFICATEID: 10 <br />CERTIFICATE EXPIRES: 11-01-2015 <br />11-01-2014/11-01-2015 <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 10 days advance written notice to the employer. <br />We will also give you 10 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 />t; e� !/cr.. , fC.7 xe nwti <br />Authorized Representative/ President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #1800 - HERRERA, JOHN PRESIDENT - EXCLUDED. <br />ENDORSEMENT #1600 - HERRERA, MARRISAL VICEPRES - EXCLUDED. <br />EMPLOYER <br />GOVERNMENT STAFFING SERVICES INC SP <br />PO BOX 718 <br />IMPERIAL BEACH CA 91933 <br />[SCM,CNj <br />IREv.7-20141 PRINTED : 12-17-2014 <br />