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WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY stateFaam <br />INFORMATION PAGE <br />23- 0450 -FBBA <br />POLICY N0. 92- CQ- F524 -7 COVERAGE IS PROVIDED BY <br />REPLACES N0. 92- BL- F765 -6 STATE FARM FIRE AND CASUALTY COMPANY <br />900 OLD RIVER RD, BAKERSFIELD CA 93311 -9501 <br />1. NAMED INSURED & MAILING ADDRESS NCCI CARRIER CODE NO. 14842 <br />SANTA ANA CHAMBER OF COMMERCE FEIN 951190030 <br />ATTN MARTY PETERSON LOCATION: <br />1631 W SUNFLOWER AVE STE C35 1631 W SUNFLOWER AVE STE C35 <br />SANTA ANA CA 92704 -7460 SANTA ANA CA 92704 <br />INSURED IS NON PROFIT CORPORATION <br />COPYRIGHT 1987 NATIONAL COUNCIL ON COMPENSATION INSURANCE <br />2. THE POLICY PERIOD IS FROM 02/01/2015 TO 02/01/2016 12:01 A.M. STANDARD TIME <br />AT THE INSURED'S MAILING ADDRESS. <br />---- -------------------------------------------------------------------------- <br />3A. WORKERS COMPENSATION INSURANCE: PART ONE OF THE POLICY APPLIES TO THE <br />WORKERS COMPENSATION LAW OF THE STATES LISTED HERE: CA <br />B. EMPLOYERS LIABILITY INSURANCE: PART TWO OF THE POLICY APPLIES TO <br />WORK IN EACH STATE LISTED IN ITEM 3A. THE LIMITS OF OUR LIABILITY <br />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: PART THREE OF THE POLICY APPLIES TO ALL STATES <br />EXCEPT ME, MT, ND, OH, RI, WA, WV, WY AND STATES LISTED IN 3A. <br />D. THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES: WCOOOOOOB <br />WC040360A WC040601A WC000404 WC040104 WC040416 WC040301B WC040105 <br />FE -4893 <br />------------------------------------------------------------------------------ <br />4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF <br />RULES, CLASSIFICATIONS, RATES AND RATING PLANS. ALL INFORMATION <br />REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. <br />------------------------------------------------------------------------------ <br />PREMIUM BASIS TO- RATE /$100 ESTIMATED <br />CODE NOS. AND TAL ESTIMATED AN- REMUNERA- ANNUAL <br />CLASSIFICATIONS NUAL REMUNERATION TION PREMIUM <br />---------------------------------- - - - - -- ----------- - - - - -- --- -- - - -- --- - - - - -- <br />8742 91,500 1.02 933 <br />SALESPERSONS - OUTSIDE <br />8810 <br />CLERICAL OFFICE EMPLOYEES - NOC <br />COMPANY SURCHARGE FOR INCREASED <br />EMPLOYERS LIABILITY LIMITS <br />TERRORISM 9740 <br />207,692 <br />299,192 <br />NE <br />03 <br />1,682 <br />115 <br />.I <br />MINIMUM PREMIUM $ 250 CALIFORNIA TOTAL ESTIMATED ANNUAL'PREMIUM $' 2,820 <br />PREMIUM ADJUSTMENT PERIOD SHALL BE QUARTERLY DEPOSIT PREMIUM $ 846 <br />STATE FRAUD SURCHARGE $ 2.10 <br />SEE SURCHARGE OVERFLOW PAGE <br />PREPARED 11/20/2014 COUNTERSIGNED <br />WC 00 00 01 04 -84 'Fs 80 2057 8120 BY AGENT <br />