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CERTHOLDER COPY <br />STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br />COMPENSATION <br />INSURANCE <br />FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 07-08-2009 GROUP: <br />POLICY NUMBER: 1825933-2009 <br />CERTIFICATE ID: 2 <br />CERTIFICATE EXPIRES: 01-01-2010 <br />01-01-2009/01-01-2010 <br />CITY OF SANTA ANA SD <br />ATTN: MARY AGUILAR <br />20 CIVIC CENTER PLZ 3RD FL <br />SANTA ANA CA 92701-4058 <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 10 days advance written notice to the employer. <br />We will also give you 10 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 />~k!~ `~~C../ <br />THORIZED REPRESENTATI ) PRESIDENT <br />UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING: <br />THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER; <br />EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING <br />CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS' <br />COMPENSATION LAW. <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />EMPLOYER <br />INMAN, HANNELORE RUTH DBA: <br />SERVICES <br />PO BOX 181333 <br />CORONADO CA 92178 <br />SKYLINE REAL ESTATE <br />/~ /' <br />~ / `/ <br />~++~. / y <br />~'~C~I1~E;K ASSf5td!°kt'r,F'j ;,r~,.:y <br />' [EDC,CS] <br />SD <br />IREV.Z-051 PRINTED 07-08-2009 <br />