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06/20/2008 13:57 FAX <br />POLICYHOLDER COPY <br />P.O. BOX 420807, SAN FRANCISCO,CA 84142-0807 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE : 10-01-2010 GROUP: <br />POLICY NUMBER: 0802847-2010 <br />CERTIF=ICATE Id: 419 <br />CERTIFICATE EXPIRES: 10-01-2011 <br />10-01-2010/10-01-2011 <br />CITY OF SANTA A $13 JOB:ALL CALIFORNIA SITES <br />PUBLIC WORKS A ENCY <br />20 CIVIC CENTS PLZ M-36 <br />SANTA ANA CA 9 701-4058 <br />This is to certify at we have issued a valid Workers' Compensation insurance policy in a form approved by the <br />California Insuranc Commissioner to the employer named below for the PCHOY period indicated. <br />This policy is not ubject to cancellation by the Fund except upon 30 days advance written notice to the employer. <br />We will also give ou 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 doss not amend, extend or alter the coverage afforded <br />by the policy lisle herein, Notwithstanding any requirement, term or condition of any contract or other document <br />with respect to ich this certificate of insurance may be issued or to which it may pertain, the insurance <br />afforded by the p licy described herein Is subject to all the terms, exclusions, and conditions, of such policy. <br />W?-"x ') OU04 • , <br />thorized Rep esentative Interim President and CEO <br />EMPLOYER'S LI ILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #1(00 - JAMES K. CAIN, PRESIDENT - EXCLUDED. <br />ENDORSEMENT #2(85 ENTITLED CERTIFICATE HOLDERSt NOTICE EFFECTIVE 10-01-1883 IS <br />?-? ATTACHED TO AN FORMS A PART OF THIS POLICY. <br />J a G INDUSTRI <br />(AN IND.) <br />7511 SUZI LN <br />WESTMINSTER CA <br />INC. AND/OR CAIN, JAMES K. <br />Z002 <br />SG <br />IREV.1-20101 I PRINTED : 09-117-2010 M0410