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APPENDIX C Sample Insurance Forms <br />(Concluded) <br />Sample Workers' Comp Form <br />STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142.0807 <br />COMPENSATION <br />I N S U R A N C E <br />FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />NOVEMBER 5, 1997 POLICY NUMBER! <br />CERTIFICATE EXPIRES: 12-31-98 <br />F- <br />CITY OF SANTA ANA <br />INFORMATION SERVICES M-12 ATTN LYNDA KELLY <br />P O 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 alter 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: 1,000,000 PER OCCURRENCE <br />EMPLOYER <br />r- <br />L <br />DOCUMENT THIS BACKGROUND City of Santa Ana <br /> <br />25C-51 <br />Page 39 of 39 <br />Exhibit A