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<br />CERTHllLDER copy <br /> <br />STATE <br />COMPENSATION <br />INSURANCE <br />I=UND <br /> <br />P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br /> <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />ISSUE DATE: 11-11-2007 <br /> <br />GROUP: <br />POLICY NUMBER: 1768237-2007 <br />CERTIFICATE ID: 5 <br />CERTIFICATE EXPIRES: 11-11-2008 <br />11-11-2007/11-11-2008 <br /> <br />CITY OF SANTA ANA <br />COMMUNITY DEVELOPMENT AGENCY-M-25 <br />PO BOX 1988 <br />SANTA ANA CA 82702-1888 <br /> <br />NF <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 emplover named below for the policy period indicated <br /> <br />This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer. <br /> <br />We will also give you 10 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 />tt:::-REPRESENTATI <br />EMPLOYER'S LIABILITY LIMIT <br /> <br />~~J&- <br /> <br /> <br />PRESIDENT <br />INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br /> <br />../~ <br /> <br />~ .' <br />J, '~j ~{;V1 <br /> <br />---. <br /> <br />I.. ,', <br /> <br />.-\ <br /> <br />EMPLOYER <br /> <br />RE8UILDING TOGETHER ORANGE COUNTY (A <br />NON-PROFIT PUBLIC 6ENEFIT CORP ) <br />PO BOX 329 <br />TUSTIN CA 92781 <br /> <br />NF <br /> <br />~ <br /> <br />PRINTED <br /> <br />10-17-2007 <br /> <br />lREV.2-0S) <br /> <br />NF <br /> <br />M0408 <br />