Laserfiche WebLink
POLICYHOLDER COPY <br />R O. BOX 8192, PLEASANTON, CA 94588 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 07-30-2019 GROUP; <br />POLICY NUMBER: 9023428-2018 <br />CERTIFICATE 10: 29 <br />CERTIFICATE EXPIRE5:09-01-2019 <br />09-01-2018/09-01-2019 <br />THIS CERTIFICATE SUPERSEDES AND CORRECTS <br />CERTIFICATE # 27 DATED 10-18-2019 <br />CITY OF SANTA ANA SIP <br />RISK MANAGEMENT DIVISION <br />20 CIVIC CENTER PLZ FL 4 <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 that will expire or did <br />expire as Indicated above. <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 policy described herein is subject to all the terms, exclusions, and conditions, of Such Policy. <br />r�zL2�?<G- fl..f/et +'Zr�1/f L'ca..ri+.^ .x✓`T ..esru��.., <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 2019-07-30 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY, NAME OF ADDITIONAL INSURED: <br />CITY OF SANTA ANA <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 09-01-2012 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2019-07-30 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: <br />CITY OF SANTA ANA <br />EMPLOYER <br />PEOPLE FOR IRVINE COMMUNITY HEALTH (A SP <br />NON-PROFIT CORP.) DBA: 2-1-1 ORANGE COUNTY <br />1505 E 17TH ST STE 108 <br />SANTA ANA CA 92705 <br />(SCM,CNI <br />PRINTED : 07-30-2019 <br />IREV.7-2014) <br />