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CERTIFICATE HOLDER COPY <br />STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807 <br />COM PBN SATION <br />I N S U R A N C E <br />FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />SEPTEMBER 19, 2003 GROUP: <br />POLICY NUMBER: 1703497-2003 <br />CERTIFICATE ID: 20 <br />CERTIFICATE EXPIRES: 07-01-2004 <br />07-O1-2003/07-O1-2004 <br />CITY OF SANTA ANA <br />COMMUNITY DEVELOPMENT CENTER <br />PO BOX1988 <br />SANTA ANA CA 92702 <br />This is to certify that we have issued a valid Worker's Compensation insurance policy in a form approved by the California <br />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 10 days advance written notice to the employer. <br />We will also give you 70 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 by the <br />policies listed herein. Notwithstanding any requirement, term or condition of any contract or other document with <br />respect to which this certificate of insurance may be issued or may pertain, the insurance afforded by the policies <br />described herein is subject to all the terms, exclusions, and conditions, of such policies. <br />~~ <br />AUTHORIZED REPRESENTATIVE <br />~(D~..,~ c . 6~ <br />PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE <br />EMPLOYER <br />CAMP FIRE BOYS & GIRLS CLUB <br />14742 PLAZA DRIVE #205 <br />TUSTIN CA 92780 <br />/a. ;t~ovrn AS TO Foxnn <br />Lnura Sheedy <br />Deputy Gity Attorney <br />SCIF 10262E rEPF-UI: B61 <br />