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<~; 31-?008 10:22att Fras-~OCBF +'~14-480-1933 T-340 ~ 002 --236 <br />1a+C db 00 41 A <br />VIOrginia Sare[y Gampnay I>wc <br />A STOCK COMPANY <br />1000 MQ,.'WAUI~E A'VE. <br />GLENVYEW , IIr60Q25 <br />WORKERS CpNIPENSATYON AND EMPLQYER3 LIABILITY INSURANCE P0~.1C~~r" <br />»ORLV~,~1~770N PAGE <br />NCCI N+s 19879 Poor 1W s VSQ3WP 0407046 a) <br />Nerr Ne. s VSQSWF 4007046 00 SIC Cedes Ae~e~ral alPa3cy Nau NEW <br />State Osempioym~ ~• No, er Ide~tlf~lsg Ntmbee as Itegait~ <br />FEL~t :2?-7'068923 <br />1. Iasaesd: ORANGE' COiJN7'Y BAR FOUNDATION ?roireer: 1Lilri(N3 M>DWEST IIJSYTRAK~~ 4GSNC Y i.i.C_ <br />Miaiti~ PA. BOAC 916 M~ 650 TOWN CEt~7TER DRIVE <br />Adtlrerst SANTA ANA, ~ 927,pZ Addrd~s SUITE 653 <br />COSTA MESA. CA, 92626 <br />O+ 7yp~ DBA Nose: <br />otlter,..rlcpMte.of s>.ewn above: <br />Z Tiro polit7 parbd:'!ha policy i3 firm 01/'0112406 To 41101200? 1201 A,.1di Sta~a+d Time, at the ids mailing f ddress <br />3 A. Waehsra Cor+p~ ~~~ Poet One of tho pOlie~- apQllaa tD tho Workers Coet~tion Law of the state <br />I.iebd here: CaYtfiorAiA <br />g, ~p'oy~ y : Part'l~o o~thopoilCy app~hos to woslt »1 each s~e)isted st Item 3. A. <br />TEe itanita of the 1~'1>zy ~soder Pant 1~0 #~ : Boditr ~7 dy Acxideat S 1,400,000 each accident <br />Bodly ~ by Dis~e S I,ooo,400 ~~ ~;mu <br />Bodily ~Jm9 hY Dtsea~ S 1.000,000 each etnploti ee <br />C. Otkar States Ynrar~ Part T'hnee of rho policy applies to the siatea„ if any, tissed her+~ <br />nil staaesNathr, om~, wasbl:~a. West Vim, w,~~ <br />p, This pinky inthdes tb~ese tstttera ~ sdteddes: <br />WC: 00 00 01 A WC 89 Ob l4 WC CP G7 <br />4. 'i'>s pr~eratas far [Isis poitp w®be desrsinad bq- og Mnamb sifiaaa , osasisestIon , Bt-Nt itr-e Bating rlsus..~v S,ssormarfos <br />n,8.irea la1e~- is s ~ aoi ~ ~ ssdtt r- <br />ctr cam rw. e~ ~+ >R.r rR ` E,~a <br />-r~t~.ea stoooe <br />ri.a.e set euadred ScL•ddr - ,._ _---- <br />Total MaNn~a3 Tresust <br />690+5 Vl--sirer et S~isre~ion PecA~ <br />total Standard T•ert:~ <br />~3 ~e ~H <br />S~io EYperse Cosuaat <br />Fatia~ated Annsal Presi~ <br />%95 CaBirsiss Gtutntatee Fs~d A>.asasst <br />9431 Ca~rsis Y1nNtd $+w~Ds t <br />lb3a Cisl:~rnY Warloeta' Co.dpamtisn Adsein Fn.a Ast~saet <br />9730 CaHbraia II >~'s ~d Aasassaest <br />9751 Cs!der.ia Srbsarlwt Injrtry HweLb Trent tad Apeavoeat <br />Tetd Aasownt Dre <br /> <br />9,501' <br />25N <br />9.250 <br />.t1~4 <br />~j <br />9,33" <br />18" <br />n <br />3' <br />x <br />.s <br />9,58N <br />Hl>a+rsted Deie+r , Iaterls A~rRntab ~prtadsae:~ be yrllie : ;/ ',_ : . <br />._,~ ~~ ~ <br />