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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 I2:0I 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 <br /> POLICY FORMS AND ENDORSEMENTS <br /> This section lists all the Forms and Endorsements that make up your policy. Refer to these documents as needed for <br /> detailed information concerning your coverage. <br /> FORM NUMBER TITLE STATE(S)Applicable <br /> WC 00 00 00 C Workers Compensation and Employers Liability Insurance Policy CA <br /> WC 00 04 21 F Catastrophe (Other Than Certified Acts of Terrorism) Premium Endorsement CA <br /> WC 00 04 22 C Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement CA <br /> WC 04 03 01 D Policy Amendatory Endorsement - California CA <br /> WC 04 03 10 Duty To Defend Endorsement - California CA <br /> WC 04 03 18 C Limited Liability Company Coverage/Exclusion Endorsement - California CA <br /> Endorsement Agreement Limiting and Restricting This Insurance <br /> WC 04 03 60 B Employers' Liability Coverage Amendatory Endorsement - California CA <br /> WC 04 04 21 Optional Premium Increase Endorsement - California CA <br /> WC 04 06 01 B California Cancelation Endorsement CA <br /> Countersigned by: <br /> Issue Date <br /> To report a claim, call your Agent or 1-844-325-2467 <br /> WC 99 06 85 <br /> 59985843 POLSVCS 280 INSURED COPY 000996 PAGE 41 OF 64 <br />