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<br />. <br /> <br />eERTHOLDER COpy <br /> <br />I"~ C" <br />'J - ", fi'/I <br /> <br />SC <br /> <br />STATE P.O. BOX 807, SAN FRANCISCO,CA 94142-0807 <br />COMPENSATION <br />INS U Fl A. He E <br />FU NO CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />ISSUE DATE: 06-01-2003 <br /> <br />GROUP: <br />POLICY NUMBER: 1298310-2003 <br />CERTIFICATE 10: 8 <br />CERTIFICATE EXPIRES: 06-01-2004 <br />06-01-2003/06-01-2004 <br /> <br />CITY OF SANTA ANA <br />WORKERS CaMP CLAIMS DEPT <br />20 CIVIC CENTER PLAZA M-41 <br />SANTA ANA CA 92701 <br /> <br />SC <br /> <br />This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the <br />California InS(Jrance 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 <br />by the polities listed herein Notwithstanding any require:JJ1ent, term. or con.dition of any contract or other document <br />with respect to which this certificate of insurance maybe 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 /> <br />~ <br /> <br />~~c <br /> <br />~ <br /> <br />AUTHORIZED REPRESENTATIVE PRESIDENT <br /> <br />EMPLOYER'S LIABILITY LIMIT INCLUOING OEFENSE COSTS, $1.000,000,00 PER OCCURRENCE, <br /> <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 06-01-200315 ATTACHED TO AND <br />FORMS A PART OF THIS POLICY, <br /> <br />~, <br />= <br />= <br />~ <br /> <br />- <br />~.~.~ <br /> <br />APPROVED AS TO FORM <br />}J . <br />~'!/b,-dv <br />L! ;~~., '<!H'H?\lY / <br />Clly Attorney, <br /> <br />:> <br />-< <br />N <br />-' <br /> <br />}> <br /> <br />,,' <br /> <br />o <br />w <br /> <br />EMPLOYER <br /> <br />LEGAL NAME <br /> <br />LIEN ON ME, INC. <br />PO BOX 91630 <br />PASADENA CA 91109 <br /> <br />LIEN ON ME,:11i!C AI'ID/OR <br />MEDICAL RECOVERY PLUS INC <br /> <br /> <br />