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CERTHOLDER COPY <br />M <br />P.O. BOX 8192, PLEASANTON, CA 94588 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 01 -27 -2015 <br />CITY OF SANTA ANA SG <br />20 CIVIC CENTER PLZ <br />SANTA ANA CA 92701 -4059 <br />GROUP: <br />POLICY NUMBER: 0022707 -2014 <br />CERTIFICATE ID; 8 <br />CERTIFICATE EXPIRES: 09- 01-2015 <br />09 -01- 2014/09 -01 -2015 <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 00 days advance written notion to the employer. <br />We will also give you 50days 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 t�hee� policy described herein is subject to all the terms, exclusions, and conditions, of such policy. <br />Authorized Representative President and CEO <br />UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING: <br />THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER; <br />EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING <br />CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS, <br />COMPENSATION LAW. <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #2080 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 09 -01 -2012 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY, <br />AMIRAN CONSTRUCTION AGR# TBD REVIEWED BY( EUNICE HEREDIA (PG. 2 of 2) <br />EMPLOYER <br />MIRJAWANGIR,FRANK AND MIROAHANGIR, MAUREEN <br />DSA: AMIRAN CONSTRUCTION CC <br />15145 WOODLAWN AVE STF 200 <br />TUSTIN CA 92780 <br />IVR'I,CNI <br />mesa -20111) PRINTED : 01 -27 -2015 <br />