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POLICYHOLDER COPY SP <br />P.O, BOX 8192, PL EASANTON, CA 94588 <br />SOMMENIM DER I �C?� .:'COMPENSATION INSURANCE <br />ISSUE RATE: 09-01-2019 <br />-& t POLICY NUMBER: 9023428-2019 <br />CERTIFICATE 0. 29 <br />CERTIFICATE EXPIRES:-01-2020 <br />09-01-2019/09-01-2020 <br />CITY OF SANTA ANA SP <br />RISK MANAGUMENT DIVISION <br />20 CIVIC CENTER PLZ FL <br />SANTA ANA CA 92701-4058 <br />This is to certify that we have issued a valid Workers' Compensation insurance pcsiicy 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 cani�sliatlon by the =und except upon go days advance written notice €o tine employer. <br />We will also give you �O days advance notice should this policy he cancelled prior to its normal expiration. <br />This certificate of insurance Is not an insurance policy and does not amend. extend or niter 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 rhay pertain, the insurance <br />afforded by the poiic;y described herein is subject to all the terms, exclusions, and conditions, of such policy. <br />;ro�e W�,_ <br />Autharizecl Representative €srasicient and CEO <br />EMPLOYEPIS LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER QC RRENCE. <br />ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2 €19-07-S0 IS <br />ATTACHED TO AND FORM$ A PART OF THIS POLICY, NAME OF ADDITIONAL INSURED: <br />CITY OF SANTA ANA <br />ENDORSEMENT #2085 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 09-01-2012 SS <br />ATTACHED TO AIR FORMS A PART OF THIS POLICY. <br />ENDORSEMENT #2570 ENTITLED WAIVER OF SUB O ATION EfFWTIVE 2019-PS 01 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: <br />CITY OF SANTA ANA <br />APPROVED <br />igEMENT DtvJSI N <br />09 2019 <br />EMPLOYER <br />PEOPLE FOR IRVINE COMMUNITY HEALT 4 (A SP <br />RON-PROFIT CORP,) RSA: 2-1-1 ORANGE COUNTY <br />1505 E 17TH ST STE 109 <br />SANTA ANA CA 92705 <br />€ 0400 <br />IRE.v,7-2€114I PRINTED : 08- 16 -2019 <br />