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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=UND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br /> <br />C:~::-:~~-~ <br /> <br />ATTN, KIM PFFTFFR" ' <br />20 CIV'1C CENTER PLAZA <br />SANTA ANA CA 92701 <br /> <br />01- ;<0Qj-/{¡:;3 <br />"A - ;:)-,003 - ;25.3 <br /> <br />GROUP: 000046 <br />POLICY NUMBER: 12055-2003 <br />CERTIFICATE ID: 48 <br />CERTIFICATE EXPIRES: 06-01-2004 <br />06-01-2003/06-01-2004 <br /> <br />ISSUE DATE: 12-02-2003 <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 California <br />Insurance Commissioner to the employer named below for the policy period indicated. <br /> <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 Mrein. 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 />~ <br /> <br />,d~ C. ~ <br /> <br />AUTI<OROZEO REPRESENTATIVE <br /> <br />PRES'OENT <br /> <br />EMPLOYER'S LrABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #1586 - VOLUNTEER COVERED. <br /> <br />ENDORSEMENT #2065 ENTrTLED CERTrFICATE HOLDERS' NOTrCE EFFECTIVE 06-01-2003 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br /> <br />¿.. t<; c> '2 , <br />:Ç' 'i .I. <br /> <br />% 7~G"""'" <br /> <br />¿C>~ <br /> <br />0 "--C-<- <br /> <br />~"' ¡;;,..- S T £> T E"' c....I ;:: <br /> <br /> b <br /> <br />i='-<- <br /> <br />\'I<.J. Ë r-r- <br /> <br />iLl~ <br /> <br />ÇT~o.- ~ c" a~" <br /> <br />~~~"-<" <br />I <br />~c~ <br /> <br />APPROVED AS TO fORM <br /> <br />_~~l_. <br /> <br />Laura Stitt SXe"dy <br />'\SSlS[¡llll City Allernc" <br /> <br />IS <br /> <br />EMPLOYER <br /> <br />ORANGE COUNTY CONSERVATION CORP. <br />CORP. ) <br />700 N VALLEY ST STE B <br />ANAHErM CA 92801 <br /> <br />(A NON PROFIT <br /> <br />selF 10262E <br /> <br />Aœe~,"i, œ""~" """'YOU ~. "",Iw."""~ ,""",.d, "OFFICiAl STATE FUND OOCUMENT" <br /> <br /> ;,k,\,¡i"~112.02'200J <br />PAGE I OF> <br />