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<br />STATE <br />COMPENSATION <br />INSURANCE <br />F=UN <br /> <br />P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807 <br /> <br />NOVEMBER <br /> <br /> <br /> <br />- 01 <br /> <br />I <br />CITY OF SANT A <br />ATTN VICKI <br />20 CIVIC CTR <br />SANTA ANA CA <br /> <br />L <br /> <br />This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California <br />Insurance Commissione, to the employer flamed beklw fOF the peliey perio&indl<lated... .~..~.-_.._." -'" . <br />30 <br />This policy is not subject to cancellation by the Fund except uponX., days' advance written notica to the employer. <br />30 <br />We will also give youlftN days' advance notice should this policy be cancelled prior to ~s 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 or other document w~h <br />respect to the policies <br />described to all <br /> <br /> <br /> <br />;7~ <br /> <br /> <br />AUTHORIZED <br /> <br />EMPLOYER'S L <br /> <br />MIT <br /> <br />ENDORSEMENT ~2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE <br />09/29/01 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. <br /> <br /> <br />D AS TO FORM <br />r <br /> <br />I <br /> <br /> <br /> <br /> <br />SHEPPARD INC <br />2681 DOW AVE STE B <br />TUSTIN CA 92780 <br /> <br />THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND self 102b2 (REV 1 '>,,) <br /> <br />.~,,~ <br />