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CERTHOLDER COPY <br />SG <br />P.O. BOX 420807, SAN FRANCISCO,CA 94142 -0807 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 05 -01 -2012 <br />CITY OF SANTA ANA SG <br />20 CIVIC CENTER PLZ <br />SANTA ANA CA 92701 -4058 <br />GROUP: 000623 <br />POLICY NUMBER: 0001155 -2011 <br />CERTIFICATE ID: 26 <br />CERTIFICATE EXPIRES: 05 -01 -2013 <br />05 -01- 2012/05 -01 -2013 <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 10 days advance written notice to the employer. <br />We will also give you 10 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 />Authorized Representative President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2012 -05 -01 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: <br />CITY OF SANTA ANA <br />ENDORSEMENT #1901 - PEAROSE, ABDULLAH - EXCLUDED. <br />s ., 's E , � 61� lj✓i <br />c <br />EMPLOYER <br />BLUERAY MANAGEMENT, LLC SG <br />PO BOX 12529 <br />NEWPORT BEACH CA 92658 <br />[KDM,CS] <br />(REV.8 -20101 PRINTED : 04 -30 -2012 <br />