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<br />CERTHOLDER ""D"( <br /> <br />SP <br /> <br />STATE <br />COMPENSATION <br />INSURANCE <br />FUND <br /> <br />P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br /> <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />ISSUE DATE: 10-01-2005 <br /> <br />GROUP: <br />POLICY NUMBER: 1209851-2005 <br />CERTIFICATE JD: 22 <br />CERTIFICATE EXPIRES: 10-01-2006 <br />10-01-2005/10-01-2006 <br /> <br />CITY DF SANTA ANA <br />COMMUNITY DEVELDPMENT AGENCY M-25 <br />P.D. BOX 1988 <br />SANTA ANA <br />CALIFORNIA 92702-1988 <br /> <br />SP <br /> <br />UOB:ALL OPERATIONS <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 lor 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 />~ <br /> <br />,.d~ C <br /> <br />&L- <br /> <br />AUTHORIZED REPRESENTATIVE <br />EMPLOYER'S LIABILITY LIMIT INCLUOING DEFENSE COSTS: <br /> <br />PRESIDENT <br />$1,000,000 PER OCCURRENCE. <br /> <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 10-01-1997 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br /> <br />APPROVED AS TO FORM <br /> <br />~ V-~kr--- <br />La fa Stitt Sheedy <br />Assistant City AtlOTih. \ <br /> <br />EMPU)YER <br /> <br />TH(>>(AS HOUSE TEMPORARY SHELTER (A NON-PROFIT <br />ORG. ) <br />PO BOX 2737 <br />GARDEN GROVE CA 92842 <br /> <br />IREV.2-05) <br /> <br />M0408 <br /> <br />PRINTED <br /> <br />09-17-2005 <br />