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� YJ <br />EDA µFUO nmrrf A6c b CERTIFICATE OF LIABILITY INSURANCE 3/2012 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS <br />ALTER RIGHTS <br />GOVERN THE <br />A E RDEDATE THE HOLDER. C EIS <br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, <br />BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: if the certiflcaio holder le an ADD, 1101101 <br />INSURED, the polloy(los) must be endorsed. if SUBROGATION i3 WAIVED, subject to <br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate dogs not confer rights to the <br />, ndlRrslA holder In IIQU of such endorsements <br />PRODUCER UTADAIJ - <br />^- •- -- — <br />PHONE IAfC NoY <br />Arthur J. Gallagher & CO. <br />ineuronce Brokers of California, Inc., License p0726243Milw <br />_ <br />One Market Plaaa, Spear TOWOr <br />ADD a <br />Wild <br />200 <br />INSURERS AFFORDING COVERAGE <br />_ <br />United Workers' Conpenoatio <br />San Francisco, CA 93105 <br />Susan Blenkenburg ��_ - -- <br />1HgVRERA;.NonProflte• <br />J <br />SAFBTY MATL CAS CORP <br />15105 <br />WSURED <br />INSURERS: <br />Grange County COnaarvation COrPS <br />INSURERCI <br />1053 North Raymond ?.venue <br />SURER1) t <br />SURER E <br />r1NSUR*RFI <br />Anaheim, CA 92501 <br />OVERAGES CERTIFICATE NUMBER: 30644354 REVISION NUMBER; <br />THIS iS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW NAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED. NOTWITHSTANDING ANY RECUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAYHAVE BEEN REOUCED BY PAID CLA1148- <br />U FOLIC EFF POLICY. EXP LIMITS <br />IN TYPE OFIIISURANCE POUCYNUMeER IS O MMlDD <br />fL O - EACH OCCURRENCE <br />ENERALLIASRJTY JIi <br />Z <br />D G�TOTSE OFJ � <br />IISEE e <br />47CILAIMS-MAOE D OCCUR 14£0 eW 1 one INJURY 1 _- <br />cCU.Ce11fAI. A Ar7V INJURY S <br />PER: <br />AUTOMOSILE UASIDTY <br />AtTY AUTO <br />ALLOWNEO SCHEDUL£O <br />O <br />AUTOS N0 r1 -OVMED <br />HIREDAVTOS AUTO$ W NR <br />UMBRELLA LJAB OCCUR <br />EXCESS LUa CLAIMS -IUIDE <br />DED RETENTION <br />A WO KERS 6RS•LLATION YIN 1pO NCG 001 -2013 0210111 011 <br />AJIYpROPRIEONPARINEFLE (ECUTiYE <br />OFFICERMEMOER EXCLUOEDT NlA <br />e Wolters' <br />09SCELPTIONOF OPERATIONS ILOCATIONSIVEHICLES (AmOACORD104, Addi UOlulRgmvk7SchedvN ,N Mors syeC$It10 1e4) <br />S <br />WOILY RIJVRY (Per person' <br />a001LYINJURY(PCr acrklcnli i <br />PROPER,)�,IAOE f <br />500,000 <br />E DISEASE. EAFMPLOYEEI i 5UU i VUV <br />E.L. DISEASE - POLICY UkUT ; 500,000 <br />Li at Per Coo. 1001000,000 <br />-a.L. Per Coo F Aw 2,000,000 <br />SIR $00,000 <br />SO- <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />Banta Ana Workforce investaent Board THE EXPIRATION PATE THEREOF, NOTICE WILL BE 0ELNERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />Fran Jutai !� <br />1000 Rast Santa An& Boulevard AUTHORIZED REPRESENTATIVE <br />0200h -� �5 2 L� <br />Santa Ana, CA 42701 USA U <br />Q 1000.2010 ACORO g TION, All r 111. T1vvd. <br />ACORD 25 (2410105) The ACORD name, and IDgo are registered marks of ACORD <br />deepaaen �, <br />30644354 <br />E-2-fiDt-330 <br />N <br />O <br />N <br />>K <br />W <br />