JOHNSON-FRANK AND ASSOCIATES-2009

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CERTHOLDER COPY SG P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 01-09-2012 GROUP: 000092 POLICY NUMBER: 0000678-2011 CERTIFICATE ID: 422 CERTIFICATE EXPIRES: 01-01-2013 01-01-2012/01-01-2013 CITY OF SANTA ANA SG BUILDING & SAFETY DEPT PO BOX 1988 SANTA ANA CA 92702-1988 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. 4'?"6 Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #1600 - ROGER FRANK PRIES - EXCLUDED. ENDORSEMENT #1600 - ALAN FRANK S,T - EXCLUDED. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 01-01-2008 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2012-01-09 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF SANTA ANA EMPLOYER JOHNSON-FRANK & ASSOCIATES (A CORP) SG 5150 E HUNTER AVE ANAHEIM CA 92807 [B1Q,SG] (REV.s-2010) PRINTED : 01-09-2012