Laserfiche WebLink
SC <br />/� C <br />THOLDER COPY <br />STATE P.O. BOX 807, SAN FRANCISCO,CA 94142-0807 <br />COMPENSATION <br />INSURANCE;' - <br />FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 07-01-2005 GROUP: " <br />POLICY NUMBER: 0643808-2005 <br />- -- CERTIFICATE ID: 69 <br />CERTIFICATE.. EXPIRES: 07-01-2006 <br />07-01-2005/07-01-2006 <br />CITY OF SANTA ANA'+ SC <br />CDBG PROGRAM <br />P.O. BOX 1988 <br />SANTA ANA CA 92701 <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 policies 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 may pertain, the insurance afforded by the <br />policies described herein is subject to all the terms,exclusions and conditions of such policies. <br />AUTHORIZED. REPRESENTATIVE PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000.00 PER OCCURRENCE. <br />ENDORSEMENT N2065. ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 07-01-2005 IS ATTACHED TO AND <br />FORMS A PART OF THIS POLICY. <br />APPROVED AS TO FORM <br />aura Stitt Se e <br />Assistant City Att6rney <br />EMPLOYER <br />...LEGAL NAME <br />MEXICAN AMERICAN OPPORTUNITY FOUN <br />CLAUDIA GUTIERREZ-RUFINO <br />401 N GARFIELD AVE <br />MEXICAN AMERICAN OPPORTUNITY FOUNDATION <br />to NON-PROFIT CORP. ) <br />MONTEBELLO CA 90640 <br />THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND SCIF 16266 <br />