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WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY <br />INFORMATION PAGE <br />23-1229-FAC1 <br />POLICY NO. 92-GA-0324-6 COVERAGE IS PROVIDED BY <br />REPLACES NO. 92-EW-N768-1 STATE FARM FIRE AND CASUALTY COMPANY <br />PO Box 853925, Richardson TX 75085-3925 <br />NAMED INSTREDANA &LMAILING ADDRESS <br />SANDBA RELAMPAGO DEL CIELO <br />PO BOX 315Q <br />SANTA ANA cA 92703-0158 <br />NCCI CARRIER CODE NO. 14842 <br />FEIN 953083493 <br />R p CATI N: <br />600 W ANTA ANA BLVD STE 214A <br />SAANTA ANA CA 92701-4558 <br />INSURED IS AN INDIVIDUAL <br />COPYRIGHT 1987 NATIONAL COUNCIL ON COMPENSATION INSURANCE <br />------------------------------------------------------------------------------- <br />2. THE POLICY PERIOD IS FROM 07/01/2019 TO, 07/01/2020 12:01 A.M. STANDARD TIME <br />AT THE INSURED'S MAILING ADD RRESS. <br />------------------------------------------------------------------------------ <br />3A. WORKERS COMPENSATION INSURANCE: PART <br />STATESNLISSTEDHHEREE: POLICY TO THE <br />B. EMPLOYERS LIABILITY INSURANCE: PART TWO OF THE POLICY APPLIES TO <br />WORK IN EACH STATE LISTED IN ITEM 3A. THE LIMITS OF OUR LIABILITY <br />UNDER PART TWO ARE: BODILY INJURY BY DISEASET $1,000,000 EACH EMPLOYEE <br />BODILY INJURY BY DISEASE $1,000,000 POLICY LIMIT <br />C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO ALL STATES <br />EXCEPT ME, MT, ND, OH, RI, WA, WV, WY AND STATES LISTED IN 3A. <br />D. <br />THIS <br />YWC040301D THESE ENDORSEMENTS WCOOOOOOC <br />*EFFECTIVE 07/01/19 <br />------------------------------------------------------------------------------ <br />4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF <br />RULES, CLASSIFICATIONS, RATES AND RATING PLANS. ALL INFORMATION <br />REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. <br />------------------------------------------------------------------------------ <br />PREMIUM BASIS TO- RATE/$100 ESTIMATED <br />CODE NOS. AND TAL ESTIMATED AN- REMUNERA- ANNUAL <br />CLASSIFICATIONS NUAL REMUNERATION TION PREMIUM <br />--------------------------------------------------------------------------- <br />B810 176,800 .40 707 <br />CLERICAL OFFICE EMPLOYEES - NOC <br />8868 <br />COLLEGES OR SCHOOLS - PRIVATE - NOT <br />AUTOMOBILE SCHOOLS - PROFESSORS, <br />TEACHERS OR PROFESSIONAL EMPLOYEES <br />COMPANY SURCHARGE FOR INCREASED <br />EMPLOYERS LIABILITY LIMITS <br />TERRORISM 9740 <br />44,200 <br />REVIEWED & <br />By Risk MANAC40 <br />0 T 28 <br />E ANCINE <br />221,000 <br />77 <br />03 <br />340 <br />115 <br />W-9 <br />MINIMUM PREMIUM $ 500 CALIFORNIA TOTAL ESTIMATED ANNUAL'PREMIUM $' 1,228 <br />----------------------------------------------------------- ------------------ <br />PREMIUM ADJUSTMENT PERIOD SHALL BE ANNUAL STATE DEPOSIT PREMIUM <br />RCHARGE $ 1,228 <br />FRAUD 4.00 <br />SEE SURCHARGE OVERFLOW PAGE <br />PREPARED 05/20/2019 <br />WC 00 00 01 04-84 COUNTERSIGNE <br />