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CERTHOLDER COPY <br />SC <br />P.O. BOX 8192, PLEASANTON, CA 94588 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 10-20-2016 <br />CITY OF SANTA ANA <br />20 CIVIC CENTER PLZ RM M11 <br />SANTA ANA CA 92701-4008 <br />GROUP: <br />POLICY NUMBER: 9123488-2016 <br />CERTIFICATE ID: 27 <br />CERTIFICATE EXPIRES: 01-28-2017 <br />01-28-2016/01-28-2017 <br />THIS CERTIFICATE SUPERSEDES AND CORRECTS <br />CERTIFICATE X 29 DATED 10-20-2016 <br />SC JOB:CORBIN & SW SENIOR CENTER PAINTING <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 poliic/cyyy described herein is subject to all the terms, exclusions, and conditions, of such policy. <br />��t`yC�!/�y � d/I�IMN"!' .11 ��4'tA'L{i•t..e <br />Authorized Representative President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #1600 - JOHN MANTIKAS, PRES,SEC,TRES - EXCLUDED. <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 01-28-2016 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />DULUX PAINTING <br />26 ROCKINGHORSE RD <br />RANCHO PALOS VERDES CA 90275 <br />Sc <br />[ND7,CNI <br />IREV.7-2014) PRINTED : 10-20-2016 <br />