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<br />CERTHOLDER COPY <br /> <br />STATE <br />COMPENSATION <br />INSURANCE <br />FUND <br /> <br />P.O. BOX 420807, SAN FRANCISCQ,CA 94142-0807 <br /> <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />ISSUE DATE: 06-01-2006 <br /> <br />GROUP: <br />POLICY NUMBER: 1298310-2006 <br />CERTIFICATE ID: 8 <br />CERTIFICATE EXPIRES: 06-01-2007 <br />06-01-2006/06-01-2007 <br /> <br />CITY OF SANTA ANA <br />WORKERS COMP CLAIMS DEPT <br />20 CIVIC CENTER PLA2A 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 Insurance 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 policy 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 to which it may pertain. the insurance <br />afforded by the policy described herein is subject to all the terms. exclusions. and conditions. of such policy. <br /> <br />a:::: REPRESENTATI <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: <br /> <br />~ <br /> <br /> <br />PRESIDENT <br />$1,000,000 PER OCCURRENCE. <br /> <br />ENDORSEMENT #1600 - BEVERLY A HARTIN, TRES CEO - EXCLUDED. <br /> <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 06-01-2002 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br /> <br />;!is <br /> <br />> () R}~1 <br /> <br />EMPLOYER <br /> <br />LIEN ON ME, INC DBA:LIEN ON ME INC <br />PO BOX 91630 <br />PASADENA CA 91109 <br /> <br />SC <br /> <br />(REV.2-05) <br /> <br />PRINTED 05-17-2006 <br /> <br />SC <br /> <br />M0408 <br />