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ISSUE DATE: 11-12-2014 CITY OF SANTA ANA 20 CIVIC CENTER PLZ SANTA ANA CA 92701-4058 POLICYHOLDER COPY P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE GROUP: POLICY NUMBER: - 1269831-2014 CERTIFICATE 10: 72 CERTIFICATE EXPIRES: 10-01-2015 10-01-2014/10-01-2015 SC JOB:CITY OF SANTA ANA IT STRATEGIC ROADMAP 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. Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2014-11-12 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF SANTA ANA ENDORSEMENT #1600 - ROY HERNANDEZ P S T - EXCLUDED. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 10-01-2000 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2014-11-12 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: ® CITY OF SANTA ANA EMPLOYER THIRDWAVE CORPORATION 11400 W OLYMPIC BLVD STE 200 LOS ANGELES CA 90064 SC [P1 I,SC] (REVD -2014) PRINTED : 11-12-2014 SC