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EMPLOVER:3s <br />Workera' Camper, in and Employers Liability <br />Insurance Policy <br />rn rwTCKJ rtQJ-LW U INS. CO. <br />Stock Company <br />Policy Number Policy Period— <br />From To <br />EIG 1571658 09 <br />12/01/2021 12/01/2022 <br />Iniv�re0 oMs s[e�a Ipr (n a ekM addre orthe <br />Transaction <br />RENEWAL DECLARATIONS <br />NCCI Carrier # 31283 WC1RB CARRIER# <br />00920 PRIOR POLICY NUMBER EIG157165808 <br />1. Named Insured and Address <br />Agent <br />NATIONAL POLYTECHNIC COLLEGE <br />DBA MONTEBELLO CAREER <br />UNITED AGENCIES (BURBANK) <br />1377002 <br />4105 SOUTH STREET <br />301 E COLORADO BLVD #200 <br />LAKEWOOD CA 90712 <br />P <br />ASADENA,CA 91101 <br />Telephone: 8182952263 <br />Customer # <br />Carrier # <br />31283 <br />FEIN # <br />954696502 <br />Risk ID # <br />4565527 <br />Entity of Insured <br />CORPORATION <br />Additional Locations: <br />2. The Policy Period is from 12/01/2021 to 12/01/2022 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 $ 110001000 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 <br />Assessments and Taxes $ <br />❑ This is a Three Year Fixed Rate Policy <br />Premium Adjustment Period: M Annual; <br />Countersigned this Day of <br />Issued Date: 10/22/2021 <br />Issuing Office EMPLOYERS PREFERRED INS. CO. <br />P.O. BOX 539003 <br />HENDERSON, NV 89053-9003 <br />Issued Date 10/22/2021 <br />WC990630 (6/98 Ed.) <br />Expense Constant $ 160 <br />Premium Discount $ <br />P <br />Total Estimated AnnualPremium $ 5,457 R <br />❑ Semiannual; ❑ Quarterly❑ Monthly <br />Authorized Representative <br />Rblt AfooigeneR mw. _ <br />INSURED COPY cnry Sr <br />%au Dresea.r <br />Page 1 of 4 ssxrta„aa�,,,,,xammiwx <br />