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Coverage Is Provided In: Policy Number: <br /> Liberty Ohio Security Insurance Company-a stock company �XWS (26)59 98 58 43 1 <br /> Mutual Policy Period: <br /> INSURANCE From 06/23/2025 To 06/23/2026 <br /> Endorsement Period: <br /> NCCI Co. No. IL9291 1 From To <br /> Workers Compensation and 12:01 am standard Time <br /> Employers Liability Insurance Policy at Insured's Mailing Address <br /> Information Page <br /> Named Insured Agent <br /> MATCH POINT TENNIS ACADEMY LLC (949) 334-5330 <br /> ACRISURE, LLC DBA MPX INSURANCE <br /> SERVICES <br /> EXTENSION OF INFORMATION PAGE State:CALIFORNIA <br /> ITEM 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 /> Classifications Code Premium Basis-Total Rate per Estimated <br /> No. Estimated Annual $100 of Annual <br /> Remuneration Remuneration Premium <br /> MATCH POINT TENNIS ACADEMY LLC <br /> 800 Cabrillo Park Dr <br /> Santa Ana, CA 92701-4648 <br /> NLC 001 CSN 001 state 04 exp rec link 00001 <br /> Clubs - racquet sports - including restaurant, bar or tavern <br /> employees, retail store employees and receptionists <br /> 9053 266,225.00 2.70 7, 188.00 <br /> Total Subject Premium 7, 188.00 <br /> Price Point Modification 9734 debit 1.011 79.00 <br /> Total Estimated Annual Standard Premium 7,267.00 <br /> WC Expense Constant 0900 160.00 <br /> Terrorism 9740 266,225.00 .03 80.00 <br /> Catastrophe (Other than Certified Acts of Terror.) 9741 266,225.00 .01 27.00 <br /> State Estimated Annual WC Premium 7,534.00 <br /> WC Administration Revolving Fund Assessment 0935 1.2370 93.00 <br /> Uninsured Employers Benefits Trust Fund Assessment 0937 .0818 6.00 <br /> Subsequent Injuries Benefits Trust Fund Assessment 0938 3.0148 227.00 <br /> Occupational Safety and Health Fund Assessment 0939 . 1885 14.00 <br /> Labor Enforcement and Compliance Fund Assessment 0992 . 1058 8.00 <br /> WC Fraud Account Assessment 9703 .4096 31.00 <br /> CIGA Surcharge 0936 .0000 .00 <br /> CA Total Cost 7,913.00 <br /> Countersigned by: <br /> Issue Date <br /> To report a claim, call your Agent or 1-844-325-2467 <br /> WC 99 06 84 <br /> 59985843 POLSVCS 280 INSURED COPY 000996 PAGE 39 OF 64 <br />