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IMPORTANT - THIS IS NOT A DELL, iE:N", NO MONEY UNLESS STATEMENT IS ENCLOSED. <br /> S'T,A A = t HOME OFFICE SAN FRANCISCO POLICY I ILIA ARATIONS <br /> `I it ISPORNIA WORKERS,',.COMPENSATION BAND,EMPLOY.EWS'UUABll.lTY- POLICY <br /> F UM'in <br /> ' THESE, DECLARATIONS ARE A PART OF THE WORKERS' COMPENSATION POLICY INDICATED HEREON. <br /> THIS INSURANCE IS EFFECTIVE FROM <br /> 12:01 A.M. , PACIFIC STANDARD TIME CONTINUOUS POLICV9 Q3 21,, <br /> 8-26-21 TO 8-26-22, AND SHALL <br /> AUTOMATICALLY RENEW EACH 8-26 <br /> • <br /> UNTIL CANCELLED <br /> ( ELI'T , SPECIAL E NTS, INC DEPOSIT PREMIUM $0.00 <br /> 11278 LOS ALAMITOS BLVD <br /> LOS ALAMITOS, CALIF 90720 MINIMUM PREMIUM 81,400.00 <br /> PREMIUM ADJUSTMENT PERIOD QUARTERLY <br /> N SP <br /> NAME OF EMPLOYER- ELITE SPECIAL EVENTS, INC (A CORP) <br /> TRADE NAMES- ELITE SPECIAL EVENTS, INC <br /> r <br /> LOCATIONS- 11278 LOS ALAMITOS B <br /> CYPRESS CA 90720 3958 <br /> 1 . ?Dea I CO EN:`SAIT°ION INS'UT NCE `-s:PART ONE OF THIS POLICY APPLIES TO THE <br /> WORKERS' COMPENSATION LAWS OF THE STATE OF CAL/FORMA. <br /> 2 =BMPI,0Y R.'S :LIABILITY' INSURANC. 'PAART TWO OF TRIS POLICY APPLIES TO <br /> LIABILITY UNDER THE LAWS OF THE STATE OF CALIFORNIA. THE LIMIT OF OUR <br /> LIABILITY INCLUDING DEFENSE COSTS UNDER PART TWO IS, <br /> fI$ r.,000,004=> <br /> CODE NO.. PRINCIPAL WORD AND RATES EFFECTIVE FROM 08--26-21 TO 08-26-22 <br /> INTERIM <br /> PREMIUM BASE BILLING <br /> BASIS RATE RATE* <br /> 9095-1 EVENT MARKET, FESTIVAL OR TIRADE SHOW 30000 9.24 9.99 <br /> OPERATION--ALL EMPLOYEES--N.O.C. <br /> ********BUREAU NOTE INFORMATION******** <br /> TED HOLCOMB P 50 <br /> TOM MOORE CEO,S 50 %' <br /> TOM MOORS T 0 % <br /> FEIN 260747948 <br /> TOTAL ESTIMATED ANNUAL PREMIUM $2,947 9""� Rekmanagement E lion <br /> ftei REVIEWED&APPROVED BY: <br /> COUNTERSIGNED AND ISSUED AT SAN FRANCISCO AUGUST 30, 2021 PO] L � , l � ' <br /> Ride lNanlgPmenl SpeSieNis[ <br /> SCIF FORM 10961A iREV.7^20144 IDVEII PLEASE) '.. <br />