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<br />" <br /> <br />. - <br /> <br />SC <br /> <br />STATE <br />COMPENSATION <br />INS URA N CE <br />FUND <br /> <br />POLICYHOLDER COpy <br /> <br />P.O. BOX 807, SAN FRANCISCO,CA 94142-0807 <br /> <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />ISSUE DATE: 04-01-2004 <br /> <br />GROUP: <br />POLICY NUMBER: 1621118-2004 <br />CERTIFICATE ID: ,.25 ' <br />CERTIFICATE EXPIRES: 04-01-2005 <br />04-01-2004/0,4-01-2005 <br /> <br />CiTY OF SANTA ANA-FINANCE & MGMT SVCS <br />DEPTDFBUILDING AND SAFETY <br />20 CIVIC CENTER PLAZA <br />POBOX 1988 <br />SANTA ANA CA 92702 <br /> <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 /> <br /> <br />This policy is not subject to'c,ancellation by the Fund 'e~ce'Pt>ut>6ri 30 days' advance written notice to the'employer. <br /> <br />We, will' also give YOU30daYS'aqvance nCltice, sryouldthis policy be cancelled pri(Jr<io <br /> <br />nClrmaJexpiration. <br /> <br />This ce~tificateofinsurai1c~ is not an insurance policy and does not amend;i'extt;!ndor alter the coverage afforded <br />by the p()licles listed herei~:Notwithstandlng any rE:3'quir~ment;term, or condition of a':1Y contract or other document <br />with respect to which this certificate of, insurancem,aybe. j~sued or may ,pe~tain,:the "insurance,' afforded by the <br />policies described herein is subject to all the terms, exclusions <ind conditions of such pO!,icies. <br /> <br />~ <br /> <br />~~c <br /> <br />~ <br /> <br />AUTHORIZED. RE'PRESENTA TIVE PRESIDENT <br /> <br />EMPLDVER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000.00 PER OCCURRENCE. <br /> <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE .EFFECTIVE 04-01-~004 IS ATTACHED TO AND <br />'FORMS A PART OF THIS POLICY. <br /> <br /> <br />EMPLOYER <br /> <br /> <br />LEGAL NAME <br /> <br />'5' <br /> <br />;"",' <br /> <br />L I CASS'I DY' WHJTMORE <br />6033 W CENTURY BL # 500 <br />LOS ANGELES CA 90045 <br /> <br />",' <br />'.....', <br />,/. <br /> <br />ir'.', " "J'" <br /> <br />','iF,; '" <br /> <br />..,".j'.,..; <br /> <br />"",>,:.,,;"~;:,>";:\'.:">'>""'0h "",::,':., <br />LIEBERT CASSIDY 'WHITMORE'~" <br />A PROFE~SIONAL CORPORATION <br />.;::;';>', " <br /> <br />-Z*, <br /> <br />',/;,:"..,'t <br />"Ie '/'+2:" <br /> <br />'V <br /> <br />';S; <br /> <br />,::'i;"" <br /> <br />'(REV:.3'~:03) <br /> <br />tU <br /> <br />,,< <br /> <br /> <br />L,' <br /> <br />,5;K< <br /> <br />1,)3/17/2004 <br />