Laserfiche WebLink
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />PREMIUM DISCOUNT ENDORSEMENT <br />Policy Number: 59 WEC AC9055 Endorsement Number: <br />Effective Date: 07/03/20 Effective hour is the same as stated on the Information Page of the policy. <br />Named Insured and Address: BAY SPROUTS LLC <br />655 S MAIN ST STE 200-317 <br />ORANGE CA 92868 <br />The premium for this policy and the policies, if any, listed in Item 3 of the Schedule may be eligible for a discount. This <br />endorsement shows your estimated discount in Item 1 or 2 of the Schedule. The final calculation of premium discount will <br />be determined by our manuals and your premium basis as determined by audit. Premium subject to retrospective rating <br />is not subject to premium discount. <br />SCHEDULE <br />1. Table of States <br />Alabama <br />X Illinois <br />Montana <br />South Carolina <br />Arkansas <br />Kansas <br />Nebraska <br />South Dakota <br />X California <br />Kentucky <br />New Hampshire <br />Tennessee <br />X Colorado <br />Louisiana <br />New Mexico <br />Texas <br />Connecticut <br />Maine <br />New York <br />Utah <br />Delaware <br />Maryland <br />X North Carolina <br />Vermont <br />District of Columbia <br />Michigan <br />Oklahoma <br />Virginia <br />Georgia <br />Mississippi <br />Oregon <br />West Virginia <br />Hawaii <br />Missouri <br />Pennsylvania <br />Wyoming <br />or any other State that has approved the premium discount plan applicable to the total policy premium on an interstate <br />basis at the effective date of the policy. <br />2. Average percentage discount: 3.30 % <br />3. Other policies: <br />4. If there are no entries in Items 1, 2 and 3 of the Schedule, see the Premium Discount Endorsement attached to your <br />policy number: <br />Countersigned by <br />Form WC 00 04 06 Printed in U.S.A. <br />Process Date: 05/25/20 <br />J�N <br />RAMmWmentDMsian <br />REVIEWED & APPROVEDSY: <br />--� Risk Pjanagement Analyst <br />