05-0726_HABITAT FOR HUMANITY_Insurance •
COTHOLDER COPY SP
STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807
COMPENSATION
INSURANCE
FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 07-26-2005 GROUP: 000046
POLICY NUMBER: 0008549-2005
CERTIFICATE ID: 48
CERTIFICATE EXPIRES: 01-01-2008
01-01-2005/01-01-2008
CITY OF SAN JUAN CAPISTRANO SP
32400 PASEO ADELANTO
SAN JUAN CAPISTRANO CA 92675
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
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
ENDORSEMENT X2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 01-01-2000 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
EMPLOYER
HABITAT FOR HUMANITY OF ORANGE COUNTY, INC A
NON-PROFIT CORPORATION
2165 S GRAND AVE
SANTA ANA CA 92705
[TRS,CN]
(REv.2-05) PRINTED 07-26-2006