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• <br /> • <br /> LOCAL AUTHORITY WORKERS COMPENSATION EXCESS JOINT POWERS AUTHORITY <br /> EXCESS WORKERS' COMPENSATION PROGRAM <br /> L1iUT OF COVERAGE <br /> CERTIFICATE OF COVERAGE <br /> THIS CERTIFIES THAT THE The City of San Leandro <br /> COVERAGE DESCRIBED HEREIN <br /> HAS BEEN ISSUED TO: <br /> DATE(S) OF ACTIVITY: July 1, 2011 through June 30, 2012 <br /> LOCATION OF OPERATION: Within the municipal boundaries of the City of San Leandro <br /> DESCRIPTION OF ACTIVITY: FY 1 1 -12 Funds — HOME Subrecipient Agreements <br /> ENTITY PROVIDING COVERAGE LIMITS CERTIFICATE <br /> COVERAGE EXPIRATION DATE <br /> City of San Leandro <br /> 835 East 14th Street S250,000 June 30, 2012 <br /> San Leandro, CA 94577 <br /> The following coverage is in effect and is provided through participation in a risk sharing Joint Powers <br /> Authority. The City of San Leandro is self - insured for 8250,000 with excess coverage of 825,000,000 <br /> through Local Agency Workers' Compensation Excess JPA (LAWCX). <br /> illy!( L. _ /Li <br /> DATE A 1 THORIZED SIGNATURE <br /> Mary Ann Perini, Budget & Compliance Mar /Risk Management <br /> NAME AND TITLE <br /> • <br /> Form 82 Revised 07/16 /2008 <br />