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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: 10-21-2015 GROUP: <br />POLICY NUMBER: 9058588-2015 <br />CERTIFICATE Q 25 <br />CERTIFICATE EXPIRES: 05-29-2016 <br />05-29-2015/05-29-2016 <br />CITY OF SANTA ANA SP JOB:INFLATABLE BOUNCE HOUSES <br />3006 W. CENTENNIAL RD <br />20 CIVIC CENTER PLZ SANTA ANA <br />SANTA ANA CA 92701-4058 CA 92704 <br />This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved dy 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 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 tthheeppoolliiyycyyy 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 #1901 - MORENO, JUAN - EXCLUDED. <br />Reviewed by <br />Pa (I (; i�- 6-f� - 6 <br />Carmen Acosta <br />PRc Ar ecreation <br />EMPLOYER <br />ALL STAR JUMPER RENTALS, LLC SP <br />117 N STANDARD AVE STE A <br />SANTA ANA CA 92701 <br />[P1Q,SP) <br />iREV.7-20141 PRINTED : 10-21-2015 <br />