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f <br />•� t <br />Sample Workers' Comp Form <br />STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142 -0807 <br />COMPENSATION <br />1NaUFt ANCE? <br />F V N D CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />NOVEMBER 5, 1997 <br />POLICY NUMBER: 12-31-98 <br />CERTIFICATE EXPIRES: <br />r <br />CITY OF SANTA ANA <br />INFORMATION SERVICES M -12 ATTN LYNDA KELLY <br />P 0 BOX 1988 <br />SANTA ANA CA 92702 JOB: VERIFICATION OF INSURANCE <br />L <br />This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California <br />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 ten days' advance written notice to the employer. <br />We will also give you TEN 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 after the coverage afforded by the <br />policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document with <br />respect to which this certificate of insurance may be issued or may pertain, the insurance afforded by the policies <br />described herein is subject to all the terms, exclusions and conditions of such policies. <br />AUTHORIZED REPRESENTATIVE PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: 41,000,000 PER OCCURRENCE <br />I— <br />EMPLOYER <br />_z <br />THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND SCIF (dFV 3,J5) <br />49 <br />