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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 89 06 00 B <br /> (Ed. 7-01) <br /> POLICY INFORMATION PAGE ENDORSEMENT <br /> The following items) <br /> ❑ Insured's Name(WC 89 06 01) 0 Item 3.A.States(WC 89 06 11) <br /> ❑ Policy Number(WC 89 06 02) ED Item 3.8. Limits(WC 89 06 12) <br /> ❑ Effective Date(WC 89 06 03) 0 Item 3.C.States(WC 89 06 13) <br /> ❑ Expiration Date(WC 89 06 04) 0 Item 3.D.Endorsement Numbers(WC 89 0614) <br /> ❑ Insured's Mailing Address (WC 89 06 05) ® Item V Class, Rate, Other(WC 89 04 15) <br /> ❑ Experience Modification (WC 89 04 06) 0 Interim Adjustment of Premium (WC 89 04 16) <br /> ❑ Producer's Name(WC 89 06 07) 13 Carrier Servicing Office(WC 89 06 17) <br /> ® Change in Workplace of Insured(WC 89 06 08) 0 Interstate/Intrastate Risk ID Number(WC 89 06 18) <br /> ❑ Insured's Legal Status(WC 89 0610) E3 Carrier Number(WC 89 0619) <br /> © Issuing Agency/Producer Office Address(WC 89 06 25) <br /> is changed to read: <br /> Effective inception, amended waiver to read as seen on page 2. <br /> *Item 4. Change To: <br /> Premium Basis Rate Per$100 <br /> Code Total Estimated Estimated <br /> Classifications No. Annual °f Annual Premium <br /> Remuneration Remuneration <br /> Total Estimated Annual Premium $ 14, 9 9 9 <br /> Minimum Premium $ 1, 000 Deposit Premium $ <br /> All other terms and conditions of this policy remain unchanged. <br /> New Estimated Premium 14,999.00 New Estimated Tax 755.00 <br /> Less Previously Billed 14, 999.00 Less Previously Billed 755.00 <br /> Additional Due 0 .00 Additional Due 0 .00 <br /> This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br /> (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br /> Endorsement Effective Date:0 8/15/2 0 2 5 Policy No. SAT I S 0 3 2 4 6 0 5 Endorsement No. <br /> Policy Effective Date: 08/15/2025 to 08/15/2026 Premium $ 0 . 00 <br /> Insured:Wiseplace, A CA Corp. <br /> DBA: <br /> Carrier Name/Code:Service American Indemnity Company <br /> NCCI Carrier Code No. 3 8 3 6 9 <br /> Countersigned by <br /> WC 89 06 00 B <br /> (Ed. 7-01) <br /> Q 2001 National Council on Compensatlon Insurance. Page 1 Of 2 <br />