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WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY <br />SURCHARGE OVERFLOW PAGE ® ®„ <br />PAGE NO: 01 23 -0450 FBBA <br />POLICY NO. 92- CQ- F524 -7 COVERAGE IS PROVIDED BY <br />STATE FARM FIRE AND CASUALTY COMPANY <br />900 OLD RIVER RD, BAKERSFIELD CA 93311 -9501 <br />1. NAMED INSURED & MAILING ADDRESS <br />SANTA ANA CHAMBER OF COMMERCE <br />ATTN MARTY PETERSON <br />1631 W SUNFLOWER AVE STE C35 <br />rPREPARED 11/20/2014 <br />�,innnnnnn i c n n A l l <br />FEIN 951190030 <br />LOCATION: <br />1631 W SUNFLOWER AVE STE C35 <br />CA SURCHARGE $ <br />STATE ASSESSMENT $ <br />LBR ENFMT COMPL ASMT $ <br />OCC SAFETY HLTH FUND $ <br />SUB INJ BENEFITS ASMT $ <br />UNIN EM BENEFIT ASMT $ <br />15.60 <br />10.50 <br />2.10 <br />1.80 <br />1,20 <br />1,50 <br />