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POLICYHOLDER COPY SP RO. BOX 8192, PLEA ANTON, CA 94588 OMMUM CERJ __ 1* RIPA COMPENSATION INSURANCE I ISSUE BATE: 09-01-2019 WL aGROUP: a POLICY NUMBER: 9023428-2019 �t � CERTIFICATE ID: 29 CERTIFICATE EXPIRES: 09-01w2020 09-01--2019109--01-2020 CITY OF SANTA ANA SP RISK MANAGEMENT DIVISION 20 CIVIC CENTER PL,Z FL 4 SANTA AAA CA 92701-405S 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 indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the amptoyer, We vvill also give you 30 days advance notice should this policy be cancelled prier to its normal expiration. 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 ail the terms, exclusions, and conditions, of such policy. Authorized Representative President and CEO EMPLOYER'S LLABILITY LIMIT LNCLUDING DEFENSE COSTS: $1,000,O00 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 AA ENDORSEMENT #2055 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 09-01-202 IS ATTACHED TO AND FORMS A PART OF THIS POL10Y, ENDORSEMENT #2570 ENTITLED WAIVER OF SLIBROGATION EFFECTIVE 2019- 9-01 IS ATTACHED TO AND FORMS A PART OF THIS POLICY, THIRD PARTY [SAME: CITY OF SANTA ANAL EMPLOYER PEOPLE FOR IRVINE COMMUNITY HEALTH (A SP NON-PROFIT CORP.) DSA: 2-1--1 ORANGE COUNTY 1505 E 17TH ST STE 108 SANTA ANA CA 92705 PRINTED : 08-15-2019 (REV.7.2014) M0409