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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY PN 04 99 07 <br /> (Ed. 7-17) <br /> POLICYHOLDER NOTICE <br /> NOTICE OF CANCELLATION TO CERTIFICATE HOLDER <br /> Dear Policyholder: <br /> The following provision is being added to your policy effective through: <br /> In the event that we, the Insurer, cancel this policy for any reason, including non-payment of premium, we will <br /> endeavor to send notification of such cancellation to the said certificate holder using the method(s) indicated <br /> below: <br /> Certificate Holder: City of Santa Ana, its officials, officers, and employees <br /> Mailing Address: 20 Civic Center Plaza (M-21),Santa Ana, CA 92702 <br /> Email Address: Not Provided <br /> Method of Notice: Mail <br /> Notice of cancellation is being provided only to the certificate holder at the address and/or email address listed <br /> above. Statutory requirements will determine the number of advance days notice provided for cancellation. If <br /> notice is mailed, it will be sent via regular, first-class mail to the address listed above. <br /> Notice of cancellation to the certificate holder is being provided for informational purposes only. Failure to provide <br /> such notice to the certificate holder will not amend or extend the date the cancellation becomes effective, nor will <br /> it negate cancellation of the policy. Failure to send notice shall impose no liability of any kind upon the Company <br /> or its agents or representatives. <br /> Policy No.: GRWC529454 <br /> Insured: Griffin Structures, Inc. <br /> Insurance Company: Oak River Insurance Company <br /> PN 04 99 07 Countersigned by <br /> (Ed. 7-17) <br />