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POLICYHOLDER COPY <br />P.O. BOX 8192, PLEASANTON, CA 94588 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 04-05-2016 GROUP: <br />POLICY NUMBER: 1269631-2015 <br />CERTIFICATE 10: 62 <br />CERTIFICATE EXPIRES: 10-01-2016 <br />10-01-2015/10-01-20t$ <br />THIS CERTIFICATE SUPERSEDES AND CORRECTS <br />CERTIFICATE # 72 DATED 10-01-2015 <br />CITY OF SANTA ANA Sc <br />20 CIVIC CENTER PLZ <br />SANTA ANA CA 92701-4058 <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 contractor 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 poli�cyy, described <br />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 #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2015-10-01 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED:. <br />CITY OF .SANTA ANA <br />�- ENDORSEMENT #1600 - ROY HERNANDEZ, P,S,T - EXCLUDED. <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 10-01-2000 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2015-10-01 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY, THIRD PARTY NAME: <br />-- CITY OF SANTA ANA <br />EMPLOYER <br />THIROWAVE CORPORATION <br />11400 W OLYMPIC BLVD STE 200 <br />LOS ANGELES CA 90064 <br />(Re V.7-20141 <br />SC <br />Z sf 3 <br />PRINTED 04.05-201.6 <br />SC <br />