Laserfiche WebLink
EMPLOYER: <br />Workers' Compensation and Employers Liability <br />Insurance Policy <br />EMPLOYERS PREFERRED INS. CO. <br />Policy Number From Policy Period <br />To <br />A Stock Company <br />EIG 2675029 02 <br />08/01/2020 08/01/2021 <br />1 Insi0.1e . s'sheyei�i�ere�n eatthesddms ofthe <br />Transaction <br />AMENDED DECLARATIONS <br />Effective: 08/01/2020 <br />NCCI Carrier # 31283 WCIRB CARRIER# <br />00920 PRIOR POLICY NUMBER EIG267502901 <br />1. Named Insured and Address <br />Agent <br />WILLIAM H NUESSE, MD AND MARY <br />NORTH RANCH INS SVCS INC 6860001 <br />ANN NUESSE, DO, A MED CORP <br />32110 AGOURA RD <br />867 S TUSTIN ST <br />WESTLAKE VILLAGE, CA 91361 <br />ORANGE CA 92866-3426 <br />Telephone: 8008012300 <br />Customer# <br />Carrier # <br />FEIN # <br />Risk ID # <br />Entity of Insured <br />1 <br />31283 <br />330893191 <br />264066 <br />CORPORATION <br />Additional Locations: <br />2. The Policy Period is from 08/01/2020 to 08/01/2021 12:01 a.m. Standard Time at the Insured's mailing address. <br />3. A. Workers Compensation Insurance: Part ONE of the policy applies to the Workers Compensation Law of the states <br />listed here: CA <br />B. 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 />Bodily Injury by Accident $ 1,000,000 each accident <br />Bodily Injury by Disease $ 1,000,000 policy limit <br />Bodily Injury by Disease $ 1,000,000 each employee <br />C. Other States Insurance: Part THREE of the policy applies to the states, if any, listed here: <br />All states except ND, OH, WA, 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 />All information required below is subject to verification and change by audit. <br />SEE EXTENSION OF INFORMATION PAGE <br />Minimum Premium $ 750 Expense Constant $ 160 <br />Premium Discount $ -878 <br />Assessments and Taxes $ Total Estimated AnnualPremium $ 13,284 <br />❑ This is a Three Year Fixed Rate Policy <br />Premium Adjustment Period: ® Annual; ❑ Semiannual; ❑ Quarterly; ❑ Monthly <br />Countersigned this Day of 44�744�� <br />Issued Date: 08/13/2020 Authorized Representative <br />Issuing Office EMPLOYERS PREFERRED INS. CO. <br />2550 PASEO VERDE PARKWAY, SUITE 100 <br />HENDERSON, NV 89074-7117 <br />Issued Date 08/1312020 AGENT COPY <br />WC990630 (5/98 Ed.) <br />Page 1 of 4 <br />a <br />a <br />RlekMsneganenEDMsian <br />REVIEWED&APPROVE)Sr <br />( erR.V tGhd <br />I®' <br />Risk Managenwnt Analyst <br />