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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 04 00 04 (Ed. 7-98) <br />EXTENSION OF INFORMATION PAGE <br />Schedule of Forms <br />ITEM 3D <br />Form Number <br />Policy No. MW00017162-01 <br />A~_Ahcable States <br />MDWC1000, WC040002, WC040003, WC040004, <br />WC040005, MWC12000510, WCOOOOOOB, WC000419, <br />W0000422A, WC040301A, WC040360A, WC040601A, CALIFORNIA <br />MWC14030510, MWC14040510, PN049901D, PN049902B, <br />PN049904, MPWC10000510, MJWC1000, MPIL 1007 <br />©1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. <br />From the WCIRB's California Workers' Compensation Insurance Forms Manual ©2001.4 of 28 <br />