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CERTHOLDER COPY SP P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 07-30-2019 CITY OF SANTA ANA SP RISK MANAGEMENT DIVISION 20 CIVIC CENTER PLZ FL 4 SANTA ANA CA 92701-4058 GROUP: POLICY NUMBER: 9023428-2018 CERTIFICATE ID: 29 CERTIFICATE EXPIRES: 09-01-2019 09-01-2018/09-01-2019 THIS CERTIFICATE SUPERSEDES AND CORRECTS CERTIFICATE # 27 DATED 10-1$-2018 This Is to certify that we have issued a valid Workers' Compensation Insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period that will expire or did expire as indicated above. This certificate of Insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any .requirement, term Or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein Is subject to all the terms, exclusions, and conditions, of such policy. /F�7%'Fi5'U' / U(/ct, � I�v"" ✓ j V NL�9sr+'^ �.P4A'Lf+'4�� Authorized Representatives President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2019-07-30 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF SANTA ANA ENDORSEMENT #2005 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 09-01-2012 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2019-07-30 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF SANTA ANA EMPLOYER PEOPLE FOR IRVINE COMMUNITY HEALTH (A SP NON-PROFIT CORP.) DBA: 2-1-1 ORANGE COUNTY 1505 E 17TH ST STE 108 SANTA ANA CA 92706 & APPROVED 1CtEM£NT L)IVI510N M. LAMBERT [SCM,CNI PRINTED : 07-30-2010 (REV.7-2e14)