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CERTHOLDER COPY <br />STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br />COMPENSATION <br />INSURANCE <br />FUN ~ CERTIFICATE OF WORUKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 06-01-2007 a ' ZO ~ ~~ 1, GROUP: <br />Q _ Z~~ ~ ~~ 2 POLICY NUMBER: 1298310-2007 <br />CERTIFICATE ID: 8 <br />CERTIFICATE EXPIRES: 06-01-2008 <br />OB-01-2007/06-01-2008 <br />CITY OF SANTA ANA SC <br />WORKERS COMP CLAIMS DEPT <br />20 CIVIC CENTER PLAZA M-41 <br />SANTA ANA CA 92701 <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 />This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. <br />We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. <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 />V <br />THORIZED REPRESENTATI PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT N1B00 - BEVERLY A HARTIN, TRES CEO - EXCLUDED. <br />ENDORSEMENT N208Ei ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 06-01-2002 IS <br />ATTACHED TO AND FORMS A PART Of THIS POLICY. <br />EMPLOYER <br />LIEN ON ME, INC DBA:LIEN ON ME INC SC <br />PO BOX 91630 <br />PASADENA CA 81109 <br /> <br />SC <br />M0408 <br />PRINTED 05-17-2007 <br />(RE V.2-a5) <br />