WITTMAN ENTERPRISES, LLC HIPAA BUSINESS ASSOCIATE AGREEMENT -2009

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CERTHOLDER COPY NF STATE COMPENSATION INSURANCE FUND P.O. BOX 420807, SAN FRANCISCO,CA 94142 -0807 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE • ISSUE DATE: 07 -08 -2009 r THE CITY OF SANTA ANA NF 1439 S BROADWAY SANTA ANA CA 92707 -1712 GROUP: POLICY NUMBER: 1933299 -2009 CERTIFICATE ID: 108 CERTIFICATE EXPIRES: 07 -01 -2010 07 -01- 2009/07 -01 -2010 THIS CERTIFICATE SUPERSEDES AND CORRECTS CERTIFICATE # 52 DATED 07 -07 -2009 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. tTHORI�ZED REPRESENTATI PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 07 -01 -2009 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER WITTMAN ENTERPRISES LLC 21 BLUE SKY COURT SUITE A SACRAMENTO CA 95828 WROVED AS TO FORM �-,iitt Sheedy Assiswia City Attorney E 'z' d ! �fi 6QDt NF VNV Ivi %t. [VMR,NF] (REV.2 -05) PRINTED : 07 -08 -2009