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0 0 <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />INFORMATION PAGE REVISION NO. <br />BERKSHIRE HATHAWAY HOMESTATE COMPANIES <br />? Oak River Insurance Company ® Cypress Insurance Company <br />NCCI Company Code No. ® New ? Revision Policy No. 3300059682-111 <br />? Renewal ? Reissue ? Rewrite of Prior Policy No. <br />Page 1 Issue Date Acct. No. 1000959361 State: California <br />Adjustment Date: THIS INFORMATION PAGE WITH POLICY PROVISIONS AND ENDORSEMENTS, <br />Anniv. Rate Date: IF ANY, COMPLETE THIS POLICY. <br />1. NAMED INSURED AND MAILING ADDRESS PRODUCER <br />SHARE OUR SELVES International Facilities Insurance Services, I <br />See endorsement attached. 811 Wilshire Boulevard <br />1550 SUPERIOR AVE. Los Angeles, CA 90017 <br />COSTA MESA, CA 92627 <br />Insured Is: ? Individual ? Partnership ? Corporation ® Other Non Profit <br />Other workplaces not shown above: <br />See Location Schedule <br />Insureds Identification Number(s): <br />See Schedule <br />2. The policy period is from 08/01/2011 to 08/01/2012 at 12:01 A.M. Standard Time at the insureds mailing address <br />3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: <br />California <br />B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in Item 3.A. <br />The Limits of our Liability under Part Two are: Bodily Injury by Accident $1,000,000 Each Accident <br />Bodily Injury by Disease $1,000,000 Each Employee <br />Bodily Injury by Disease $1,000,000 Policy Limit <br />C. Other States Insurance: NONE <br />D. This policy includes these endorsements and schedules: <br />See Schedule of Forms and Endorsements <br />W0000001G <br />4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information required on the <br />following Classification Schedule is subject to verification and change by audit. See Extension Schedule Attached. <br />$ 100,121 TOTAL ESTIMATED ANNUAL POLICY PREMIUM If indicated, interim adjustments of <br /> premium shall be made: <br />$ ADJUSTMENT PREMIUM DUE (Addl., or Return Premium - A minus <br /> figure means Return Premium ? Semi-Annually <br />$ 1,000 MINIMUM PREMIUM ? Quarterly <br />Monthl <br /> <br />y <br />? <br />$ 20,557 DEPOSIT PREMIUM <br />Servicing Office: <br /> <br />Secretary <br />Aunust 02 2011 <br />President <br />Page 1 <br />care <br />W0000001G