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<br />CERTHOLDER COpy <br /> <br />STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807 <br />COMPENSATION <br />INSURANCE <br /> <br />F=UN C CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />ISSUE DATE: 12-02-2003 <br /> <br />GROUP: 000046 <br />POLICY NUMBER: 12055-2003 <br />CERTIFICATE ID: 48 <br />CERTIFICATE EXPIRES: 06-01-2004 <br />06 -01- 2 003 / 06 - 01- 2004 <br /> <br /> <br />,1- ),,003 -I &3 <br />/------- "'A - ð--003 - ,;253 <br />CITY OF SANTA ~~ <br />ATTN: KIM PFRTFFRIL. .:, '\ <br />20 cnl'.IC CENTER PLAZA <br />SANTA ANA CA 92701 <br /> <br />JOB: ALL OPERATIONS <br /> <br />This is to certify that we have issued a valid Worker's Compensation insurance policy in a form approved by the Califomia <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 30 days advance written notice to the employer. <br /> <br />We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. <br /> <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 condltions,of such' policies. <br /> <br />~ <br /> <br />,&~ C <br /> <br />~ <br /> <br />AUTHOROZED REPRESENTATIVE <br /> <br />PRESIDENT <br /> <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br /> <br />ENDORSEMENT #1586 - VOLUNTEER COVERED. <br /> <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 06-01-2003 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br /> <br />?~c>'2. , <br />~~I. <br /> <br />% 7~Gc",," <br /> <br />¿=~ <br /> <br />o<--C-'- <br /> <br />-\"' ~ os ToT'" G s: +:: <br /> <br /> b <br /> <br />~ <br /> <br />'T\ð, E:..v- <br /> <br />IL,~ <br /> <br />ç ~.:..I.- ~ c." b.~ €' <br />~ .:...c~'<..<"1 <br />~c~ <br /> <br />APPROVED AS TO fORM <br /> <br />'~;~:;;' <br /> <br />'\SSiS(¡ll1[ City Aller"ev <br /> <br />IS <br /> <br />EMPlOYER <br /> <br />ORANGE COUNTY CONSERVATION CORP. <br />CORP.) <br />700 N VALLEY ST STE B <br />ANAHEIM CA 92801 <br /> <br />(A NON PROFIT <br /> <br />selF 10262E <br /> <br />At:œpt1hi'œrtifiœlo "",,""" ~. ""'tw.Io"",~ thol ~"'" 'OFFICIAL STATE FUND DOCUMENT" <br /> <br />W~I'iii\r¡':12.02'2003 <br />PAGE' OF: <br />