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<br />- ( <br /> <br />- <br />. <br />. <br />=== <br />- <br />-= <br /> <br /> <br />o <br />o <br />. <br />"'= <br />- <br />, <br />o~ <br />, <br />- <br /> <br />C- <br />O <br />0= <br />-- <br />" <br />= <br />'- <br /> <br />00.224 <br /> <br />NOV-18-2~2 15:08 DGWB <br />.' "Ii'avelersPropertyCasuaItYJ <br />A"'-Mrd. Tl'I2vehnGroqp <br /> <br />7148812442 P.02 <br /> <br />WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br /> <br />TYPE v <br /> <br />INFORMATION PAGE we 00 00 01 ( A) <br /> <br />POLICY NUMBER: (LJUB-170KG82-1-02) <br /> <br />POLICY ISSUED <br />REPLACED UNDER SAME NUMBER <br /> <br />INSURER: THE TRAVELERS INDEMNITY COMPANY OF ILLINOIS <br /> <br />,. <br /> <br />INSURED: <br /> <br />DGWB. INc. <br />217 N. MAIN STREET <br />#200 <br />IRVINE CA 92701 <br /> <br />NeCI Co CODE: 13579 <br /> <br />PRODUCER: <br /> <br />MARSH USA INC <br />DELCINE CHARLES, CASUALTY DEPT <br />1166 AVE OF THE AMERICAS 40 FL <br />NEW YORK NY 10036 <br /> <br />Insured is A CORPORATION <br />Other work places and identification numbers are shown in the Schedule(s) attached. <br />2. The policy period is from 04-10-02 to 01-01-03 12:01 A.M. at the insured's mailing addresss. <br /> <br />3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers <br />Compensation Law of the slate(s) listed here: <br /> <br />CA <br /> <br />B. EMPLOYERS LIABilITY INSURANCE: Part Two of the policy applies to work in each state listed in <br />Item 3.A. The limits of Our liability under Part Two are: <br /> <br />Bodily Injury by Accident: $ 1000000 Each Accident <br />Bodily Injury by Disease: $ 1000000 Policy limit <br />Bodily Injury by Disease: $ 1000000 Each Employee <br /> <br />C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: <br /> <br />AL AR AZ co CT DC DE FL GA HIlA 10 IL IN KS KY LA MA Me ME MI MN <br />MD MS MT NC NE NH NJ NM NV NY OK OR PA RIse SO TN TX UT VA VT WI <br /> <br />D. This policy indudes these endorsements and schedules: <br />SEE LtSTING OF ENOORSEMENTS - EXTENSION OF INFO PAGE <br /> <br />4. The premium for this policy will be determined by our Manuais of Rules, Classifications, Rates and Rating <br />Plans. All required information is subject to verification and change by audit to be made ANNUALLY. <br /> <br />DATE OF ISSUE; 04-11 -02 LK <br />OFFICE: NEW YORK <br />PRODUCER: MARSH USA INC <br /> <br /> <br />140 <br /> <br />AS J FORM <br /> <br />CRI NE LEE SHAW <br />Deputy City Attorney <br /> <br />G8205 <br /> <br />TOTAl P.02 <br />