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Ted Holcomb <br />443 <br />c. <br />P.4 <br />STATE HONE OFFICE SAN FRMCISCU ANNUAL RATING ENDORSEk1ElNT <br />CO MPENSArION <br />I N S U R A N C B IT IS AGREED T"r 7wE CLASSIFICATIONS AND RATES PER $100 OF REMNEFIATION APPEARING <br />FUN IN THE CONTINUOUS POLICY ISSUED TO THIS EMPLOYER ARE AMENDED AS SHOWN BELOW, <br />Dec 14 07 10:01a <br />r Pumr- meLm nCar rsA1C3 rwK T11t PEHIQL) INDICATEO_ IF YOUR NAME OR AMPIESB SHOULD <br />BE CORRECTED OR IF INSURANCE IS NOT NEEDEC FOR NEXT YEAR, PLEASE TELL USN. <br />IMPORTANT THIS IS NOT A BILL CONTINUOUS POLICY 1848138-07 <br />SEND NO HONEY UNLESS STATEMENT IS ENCLOSED <br />THE RATING PERIOD BEGINS AND ENDS AT 12:01AN RATING PEAIOD 4-01-07 TQ 4-01-08 <br />PACIFIC STANDARD TIME <br />NORTH AMERICAN AMUSEMENTS, INC DEPOSIT PREMIUN $44,649.00 <br />11101 CALABASH AVE MINIMUM PREMIUM $354.0D <br />FONTANA, CALIF 92337 PREMIUM ADJUSTMENT PERIOD MNTALY <br />REP 31 R SD <br />NAME OF EMPLOYER- NORTH AMERICAN AMUSEMENTS, INC <br />(A CORPORATION) <br />CODE NO. PRINCIPAL WORE AND RATES EFFECTIVE FROM 04-01-07 TO 04-01--08 <br /> INTERIM <br /> PREMIUM SASE BILLING <br /> BASIS RATE RATE'k <br />9016-1 AMUSEMENT PARKS OR E MIBITIONS 383573 10.01 8.55 <br />8810-1 CLERICAL OFFICE EMPLOYEES--N.O,C_ 29287 1.16 .99 <br />9180-1 AMUSEMENT PARKS OR EXHIBITIONS 122392 7.77 6.63 <br />EXPERIENCE MODIFICATION <br />4-01-07 TO 4-01-08 326 2 <br />*,e** ***BUR$AU NOTE INFORMATION* <br />?° <br />FEIN 330709455 <br />FEIN 330744068 <br />l!6 ?'4 ,. s ?'Z''Yl o <br />TOTAL ESTIMATED ANNUAL PA$MIUlI $134,285 <br />1UN E S I NED jD I S SUED AT SAN FRANC I? SCO OVEFt PLEASE"R I L 12 , 2007 POLICY L PAGE 1 OF <br />3 <br />25A-19