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POLICYHOLDER COPY <br />SP <br />P.O. BOX 8192, PLEASANTON, CA 94588 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 05-27-2024 GROUP: <br />POLICY NUMBER: 9133408-2024 <br />CERTIFICATE ID: 35 <br />CERTIFICATE EXPIRES: 05-27-2025 <br />05-27-2024/05-27-2025 <br />Anie Digitally signed <br />CITY OF SANTA ANA SP g 20 CIVIC CENTER PLZ by Angie Acevedo <br />SANTA ANA CA 92701-4058 Date: 2024.06.10 <br />Acevedo 10:36:01-07'00' <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 indicated. <br />This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. <br />We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. <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 />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 2023-05-27 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 05-27-2023 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />ENDORSEMENT #1651 - SANTIAGO RODRIGUEZ, P - EXCLUDED. <br />ENDORSEMENT #1651 - CYNTHIA RODRIGUEZ, S,T - EXCLUDED. <br />EMPLOYER <br />F RiskMougmumtDMslcrn <br />AMERICA TRUCK DRIVING SCHOOL, INC. SP REVIEvuED&APPROVED BY. <br />2210 N MAIN ST STE B <br />SANTA ANA CA 92706 <br />— Risk Management Specialist <br />(REV.7-2014) PRINTED : 06-05-2024 <br />