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III!' .I . 41 <br />Workers' Compensation and Employers Liability <br />Insurance Policv <br />EMPLOYERS ASSURANCE CO. <br />Policy Number From olicy PeriodToA <br />Stock Company <br />EIG 1117026 16 <br />10/15/2024 10/15/2025 <br />12:01A.M. Standard Time at the address ofthe <br />Insured as stated herein <br />Transaction <br />AMENDED DECLARATIONS <br />Effective: 10/15/2024 <br />NCCI Carrier # 36870 WCIRB CARRIER# <br />00919 PRIOR POLICY NUMBER EIG1 11702615 <br />1. Named Insured and Address <br />Agent <br />ARGO ENTERPRISES INC <br />ADP - FLORHAM PARK - SERVICE 0033001 <br />DBA UNISHIELD <br />FLORHAM PARK - SERVICE <br />599 4TH STREET <br />1 ADP BLVD., M/S 625 <br />SAN FERNANDO CA 91340 <br />ROSELAND, NJ 07068 <br />Telephone: 8005247024 <br />Customer # <br />Carrier # <br />FEIN # <br />1 <br />Risk ID # <br />1 <br />Entity of Insured <br />36870 <br />954718550 <br />CORPORATION <br />Additional Locations: <br />2. The Policy Period is from 10/15/2024 to 10/15/2025 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 <br />Assessments and Taxes $ <br />❑ This is a Three Year Fixed Rate Policy <br />Premium Adjustment Period: ® Annual; <br />Countersigned this Day of <br />Issued Date: 02/03/2025 <br />Issuing Office EMPLOYERS ASSURANCE CO. <br />P.O. BOX 539003 <br />HENDERSON, NV 89053-9003 <br />Issued Date 02/03/2025 <br />WC990630 (5/98 Ed.) <br />f <br />Expense Constant $ 160 <br />Premium Discount $ <br />Total Estimated Annual Premium $ 8,656 <br />❑ Semiannual; ❑ Quarterly; ❑ Monthly <br />INSURED COPY <br />Authorized Representative <br />Page 1 of 3 <br />