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N-2018-112 awarin .roenr�rrw+uaaaar <br />Foacy, Park <br />oky <br />9EiiP1.S?YB€5 1N5. CXT, 'Poicy Number �fi�r � �s,�,,;� <br />A.Stock Company 91C 2tizldl m 00 ��[9Mizoia <br />POLICY GtECLAi2ATlONS <br />NCCf asaft r # 3 1 3 W CRIB C:ARtd 0092 . PRIOR POLICY NUMSER NEW <br />91 Named tnseuad and Ad _ '.A. t <br />NANCY ALCALA NETWORKED INS AGENTS- CA ONLY 0938001 <br />t24t47 H CKtNtR ,Akt 57UAi0 443 GRASS VALLEY, CAWN POINT �969 5 R UNIT A j �R:��• <br />SANTA ANA CA 927074408 <br />Telephonic 53027469W <br />r r rtFN r Mk i@ r to tY ar to sxsei _ <br />Additional! Locatkaw <br />2, the Pa#cy Period !s #ttxn05101f2014 to 06/0112019 12:01 a,m. Standard Time at the insomIT's mulling address. <br />3. A, Workers Compreventon Insurance: Part ONE of the policy applies to the Workers Compensation Law of the states <br />listed hero: CA <br />8, Employers Liability insurance: Part TWO of the policy applies to work in each state listed In item 3A. <br />The limits of our liability under Part TWO are: <br />dRuddy Injury by Accident $ 1.00M000 each accident <br />Bodily Injury by Disease $ 1.000.000 policy limit <br />Randy Injury by Disease $ 1.000,000 each employee <br />C. Other States f rwumcv: part THREE of the policy applies to the states, if any, listed hers; <br />Alf states except AK, DE, HL NO, NH, OH, RI, WA, WV, WY and states listed in item 3.A. <br />D. This policy Includes these endorsements and schedules: See attached schedule. <br />4, The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans. <br />Alf Infiamistran required below is subject to verification and change by audit. <br />SEE EXTENSION OF INFORMATION PAGE <br />mwmum Poompan 750 Expense Constant $ 220 <br />Premium Discount $ <br />Assessments and Taxes $ Total Estimated Annuall remium $ 782 <br />d This Is a Those Year Fixed Rate Policy <br />Premium Adjustment Per'rtxf; fM Annual, 0 Semiannual: 0 Quarterly; Monthly <br />Countersigned this Day of Ph - <br />Issued Date. 04124/2018 Authorized Representative <br />Issuing Office EMPLOYERS PREFfflfW INS. CO. <br />7110 NORTH FRESNO STREET, SUITE 250 <br />FRESNO, CA 93720.2999 <br />t"We Date 0412412018 INSURED COPY <br />WC990630. 18108 £dJ <br />Pegs 1 0f 2 <br />