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CERTHOLDER COPY <br />STi4TE P.O. BOX 420807, SAN FRANCISCO,cA 94142-0807 <br />COMPENSATION <br />I N S U R A N C E <br />CERT[FICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 04-14-2009 GROUP: 000567 <br />POLICY NUMBER: 0000772-2008 <br />CERTIFICATE ID: 17 <br />CERTIFICATE EXPIRES: 04-14-2010 <br />04-14-2009/04-14-2010 <br />CITY OF SANTA ANA SP <br />COMMUNITY DEVELOPMENT AGENCY <br />PO BOX 1988 <br />SANTA ANA CA 92702-1988 <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 30 days advance written notice to the employer. <br />We will also give you 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 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 />THORIZED REPRESENTATI PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE C05TS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT ;~f2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 04-14-2008 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />® APPROV ~.~ ~,, ,. ~~ i- ~ .. . <br />Laura Stit~ il•'--~ Y <br />Assistant City Attorney <br />EMPLOYER <br />ORANGE COUNTY CHILDREN'S THERAPEUTC ARTS <br />2215 N BROADWAY <br />SANTA ANA CA 92706 <br />SP <br />[GJS,CN] <br />SP <br />Fv.~-nsi PRINTED 04-01-2009 <br />