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FROM :DIXIE DIESEL nn ELECTRIC FAX N0. :56269548171] Aug. 14 217178 82 : 3aPM P4 <br />i , <br />~RRTWOLDER C0~'Y <br />,~ <br />CaDMplB[v>S,~-'elt'?N' P•O. BOX ~~0~3i77, 5AN FRAN~ISCO,CA J4142~0807 <br />IN'~UfiAF1CE f <br />C~NTIFIC;AY~ O,~ W4FtKBakS' CGIMIs@N$ATI~N IN$URAI~CE <br />Issut* oars: o7-ae-2opa f GRC~tJP: ~ ' <br />PQLICY WUMB~R: 1?77f~{6^ZOgE <br />' i' C~FfTIFICATE" Ip; 9af <br />GE~1"IFICATE &XPIR6S:OZ-gf-9t'!pE <br />' a2-x~-soot/oa.s1-~aoo <br />' i~ I <br />CITY OF SANTA ANA ~ ' <br />20 c1tYlc Esc <br />CENT <br />is~ v <br />~.x <br />SANTA ANA CA 927t)~~4pt38 ~ <br />I ~~ I ' <br />' j <br />' I' ' ! ~ ~ <br />Thfs Is to certify that wo ,have lsgued a baltd Workdr~' Con+pensation InSUranab <br />California Insurance Cgmmissioner,to ~theiprrrpioyar named.66i0w tar the allc policy in;a ibrm approved by the <br />p Y perlbd InQicatad: <br />Thfs policy is not subject ~Yo canCetiaSionl by the Fund'gk4ept upt~rt'y~}' dey~ ridvgnaa Vvrittari ftotiC6 tp the 0mployer. <br />' .~ <br />We will also givo Y~ 3~ days edvAnca tiotic~ should this poltcY I'd canp$lied prior tq Its normal expiratlpn, <br />This c6rtifiCa{® of ;nsvanae is not ah in~urOnCe pelioy and dnea net ,~phq wxtpnd .or r;tsr thr; aoveroy~ +~fford~pd <br />by the policy listed hareln.~ NatWithstaedl~q ynY reC~uirerrJent, term :or aarxllt(an bf a <br />with rcaperot td vtrhich thl& certificate of tlal/l'ahaa may bo liourd pr tp whioh ft m~'COntract or other dacume/1C ~ <br />afforded by th@ paliey described herein i siubjrGt to ail Y F'+eJ`f+l^. the Insurancr' ' <br />the trrmit, axclaminnm. ark a~nditiaha, of auoh policy. ' <br />i <br />HORI2Ep REPRB$~JVTATI ' <br />~ ~ ('FiESIpf;NT <br />MPI.OYER S lrSABILYTY ~i <br />MIl` r [11QING DEF~N$~ C0571S; t1,DCQ..t?Qt3 I~CR OCCJ:IRRtNCe. <br />ENOORSeM1sNT NRfgfiS ' 6NTiYLEp Abd ~!~Nq~, INBIJREO EMP~,pIYJt:R ,EFFE(itx'1(E i ZOOS-07-o8 IS <br />ATTACHED TO MID FORD A PI~tiT 0 THi~S POLICY, NAME OF AoDiTI0NA1. ~N5tJ1R~D: ' <br />CITY OF SANTA ANA. <br />4t~ORSEMEN7 #18Op ~- 41AMES ~SKAF p, T - <br />,~ ~xCi.uDED. <br />ENOORSBMENT #~gIE ITLEd ~ FY~ATE HD6OER$' NOTICE EFFECTIVE 0~-4f-gq¢A I~ f <br />ATTACHED TO AND PdRI~$ A PART;Op'TNY9 POLYCY. <br />I <br />I ; ~ '~ <br />.~ ~ I <br />i ~ : ~ <br />I'. <br />~ i ~~~ <br />EMPLQwER ~ ~ <br />i <br />~: i <br />~. <br />DIxlfi blESEI a Bl. <br />EdTRIC, YNC <br />t 16ts~ 1fASHINGTtaN BLVD' Srl~ !' ~ ~ <br />'MWITTIER CA f1000a ' i I ' <br />: <br />' <br />V.~-oel <br />PRiNTFip P7-pit-$i7~Q <br />b01z0 39tid I V7~1f1SNI 113~Ji~3Fi0 ! ~ ~016E-L6t~W508 6T ~ST 800Z/80/L0 ~ ' <br />