Laserfiche WebLink
CERTHOL DER COPY <br />SP <br />P,O, BOX 8192, PLEASANTON, CA 94588 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 09-06-2019 <br />CITY,OF SANTA ANA <br />RISK,MANAGEMENT DIVISION;- <br />20 CIVIC CENTER PLZ <br />SANTA ANA CA 82701-4058 <br />SP <br />GROUP; <br />POLICY NUMBER;. 92599t91-2019 <br />CERTIFICATE ID-. 1 <br />CERTIFICATE EXPIRES: 08-30-2020_ <br /><08-30-2019y08-30-2620 <br />This Is to certify that we have Issued a valid Workers' Compensation insurance. policy in e form approved by the <br />California Insurance Commissioner to the employer named below for the -policy period indicated. <br />This policy i9 not subject to cancellation by the Fund except upon SO days advance written notice to the employer. <br />Wa will also tdeVe :.you 30da" 1011111 notice should this Policy be carrceliad;pdor to its nor <br />mal expiration. <br />This certificate of :insurance is not an Insurance policy and does not amend, extend ar :altar 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 wrilltih it may partaiin, the insurance <br />afforded by the <br />'3Pollii�cTyydescribbeed herein Is subject to ail the terms, oxciusions, and conditions, of such policy. <br />Authorized Reprasontative % President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS:' $J,DOO,OOQ dPfR OCCURRENCE <br />ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2019-09-06 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: <br />CITY OF SANTA ANA <br />ENDORSEMENT H2O65 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 09-06-2019 IS <br />ATTACHED To AND FORMS A PART OF THIS POLICY, <br />& APPROVED <br />ICtEMENT DIVisiON <br />EMPLOYER A 13 2aig <br />SANTA AAA AVE'SDFT9ALL Sp ZIAM�/ <br />T] <br />28f&. W AI:TON HA M. LAMBERT <br />tlN AVE <br />SANTA ANA CA..92704 <br />(SITY,CN) <br />f8EV.7-2014) <br />PRINTED : 09-OG-2019 <br />