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Sent By: RACE CENTRAL; <br />909+874+2604; Sep-25-17 2:50PM; <br />CERTHOLDER COPY <br />Page 2/3 <br />SP <br />ISSUE DATE: 08-25-2017 <br />P.O. BOX 8192, PLEASANTON, CA 94588 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE' <br />CITY OF SANTA ANA <br />PARKS RECREATION AND COMMUNITY SERVICES <br />20 CIVIC CENTER PLZ <br />SANTA ANA CA 92701-4058 <br />F71;7 <br />GROUP <br />POLICY NUMBER: 11102SS-2015'. <br />CERTIFICATE ID, 10 <br />CERTIFICATE EXPIRES: 12-01-2017 <br />12-01-2016/12-01-2017 <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 tp 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 doOment <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 />Authorized Representative President and CEO <br />UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING: <br />THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AN6 WIFE EMPLOYER; <br />EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFpRDING <br />CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS' <br />COMPENSATION LAW. <br />_i EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS; $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2017-09-25 15 <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED; <br />CITY OF SANTA ANA <br />ENDORSEMENT N2085 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 12-01-1908 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />IKENDCRRY, DENNIS AND IKENBERRY, JUDY <br />228 S OLIVE AVE <br />RIALTO CA 02376 <br />IREV.7-ie141 <br />SP <br />(NKH,CNI <br />PRINTED : OB-25-2017 <br />