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<br />. <br /> <br />. <br /> <br />411tERTHOLDER COPY <br /> <br />STATE PO sox 807, SAN FRANCISCO;CA 94142-0807 <br />COMPENSATION <br />INSU~"'NCE <br />FUN 0 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />SC <br /> <br />ISSUE DATE, 06-01-2004 <br /> <br />.It> ~ooo-111 <br /> <br />GROUP, <br />POLICY NUMBER, 1298310-2004 <br />CERTIFiCATE ID: 8 <br />CERTIFICATE E;';PIRES, 06-01-2005 <br />06-01c2004/06-01-2005 <br /> <br />C1JYOF SANTA ANA <br />WORKi:RS.COMP CLAIMS DEPT <br />20 CIVIC CENTER PLAZA M-41 <br />SANTA ANA CA 92]01 <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 />Calitornialnsurance Commissioner to the empldyer named below for the POlicy period indicated. <br /> <br />This poli~y is not subject to cancellation byt~e Fund except upon 30 days' advance written notiqe to the employer. <br /> <br />We will also giveYOl..l:30days"advance notice should this polLeY be cancelled prior to its norm~lexpiration. <br /> <br />This certificateotinsu~an(::jsp6tan i~su[ance policy, and does riot amEmdi- extend or alter thec:overage a:fforded <br />by the pplicies listed hereill:,l\Jqtwithstandil)9,,tl:nY,,reql11r',!;!fTlent, term, or cOQditlon oJ any contractor other docum:enJ <br />with res~ct to which this certificate of in:surancemaY~l:le'is:sued or may pert:iiin, 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 />t1~c <br /> <br />~. <br /> <br />AUTHORIZED flEPREScNTATIVE PRESIDENT <br /> <br />EMPLQYE~'S LIABILITY !-IIoln INCLUDING DEFENSE COSTS: ~1 ,000, OOO.QO PER. OCCURRENCE. <br />~NQORSEMENT #2065 ENTtTtEQ CE~T!fICAT~ HOLDERS' NonpEEFFECTI\I~ 06-01-2004 IS ArrACHEDTD AND <br />FORMS A PART OF THIS POLICY, <br /> <br />gg <br />.= <br /> <br />~.ay <br /> <br />:z: <br />". <br />'-< <br />r..) <br />...J <br /> <br />1J <br /> <br />~ <br />o <br />w <br /> <br />EMPLOYER <br /> <br />LEGAL NAME <br /> <br />LI rNON ME. I C; <br />PO BOX 91630 <br />PASADENA CA 91109 <br /> <br />LI EN ON ME IHC <br /> <br />.;:E" <br />0- <br />C1D~ <br />::r.-< <br />:::orr1o <br />Q'1_~,;rrl <br />gP? <n <br />-n':!> <br /><02: <br />~~)') <br />s;::);. <br />:::r0l: <br />c..:,,':t>> <br /> <br />(REV 3-03) <br /> <br />PRINTED' 05/17 /2()O4 P0408 <br /> <br />~'l-- <br /> <br />THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND selF 10265 <br />