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CAM 338 S Wabash <br />Chicago, Illinois 60504 STANDARD WORKERS COMPENSATION <br />AND EMPLOYERS LIABILITY POLICY <br />INFORMATION PAGE -- RENEWAL OF Wc.,, 5 94410332 <br />Policy Number Frompolicy Period To Coverage Is Provided By Agency <br />WC 5 9441.0332 09/06/1 VALLEY FORGE INSURANCE COMPANY <br />Named! And Address 1051519410 <br />BARRY A. ROSS APC Agent <br />33 Springwood S&S/WELLS FARGO INSURANCE, INC. <br />IRVINE, C N9306-130 <br />CA 733 MARQUETTE AVE 13TF FLOOR <br />I <br />E <br />92604 INNEAPOLIS MN 55402 <br />0 T I C E S C H E D U L E SCHEDULE <br />PAGE I <br />THE FOLLOWING POSTING NOTICES WILL BE ATTACHED TO THE POLICY <br />ST CNA FORM STATE FORM FORM DESCRIPTION QTY <br />CA I G301245A DWC 7 Workers Compensation Notice <br />CA G301246A DWC 7 Worker001 <br />Workers Compensation Notice (Spanish) 001 <br />CA WC9493 Whistleblowers Are protested (English) 001 <br />CA G301268A WhistlebjOWQrS Are Protected {Spanish) 001 <br />CA WC9908A FACT SHEET D ANSWERS TO YOUR QUESTIONS ABOUT PERMANENT 001 <br />DISABILITY BENEFITS (ENGLISH) <br />2 �2 CA WC9916 FACT SHEET D <br />ANSWERS TO YOUR QUESTIONS ABOUT <br />PERMANENT 001 <br />,F, DISABILITY BENEFITS (SPANISH) <br />THE FOLLOWING POSTING NOTICES WILL BE MAILED UNDER SEPARATE COVER <br />N <br />ST CMA FORM STATE FORM FORM DESCRIPTION QTY <br />Mae <br />DATE OF ISSUE- 0'7!23/14 <br />POLICY ISSUING OFFICE: MINNEAPOLIS <br />!Lq! <br />