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POLICYHOLDER COPY SP P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 03-30-2018 CITY OF SANTA ANA C.O. LETICIA LOPEZ SP 20 CIVIC CENTER PLZ SANTA ANA CA 92701-4058 GROUP: POLICY NUMBER: 9149967-2017 CERTIFICATE ID: 12 CERTIFICATE EXPIRES: 12-30-2018 12-30-2017/12-30-2018 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 3O 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 2018-03-30 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF SANTA ANA C.O. LETICIA LOPEZ ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 12-30-2016 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #1650 - KENNETH FORNESS P,S,T - EXCLUDED. EMPLOYER FORNESS CONSTRUCTION INC. SP 1141 ROSEMARY CIR CORONA CA 92879 [P11,H0] fREV.7-2014i 1rINTED : 03-30-2018 REVIEWED BY: EUNICE HEREDIA (PG VOF )