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w <br />evANAv S93 S Wabash <br />Ohicago, Illinois 60904 <br />STANDARD WORKERS COMPENSATION <br />AND EMPLOYERS LIABILITY POLICY <br />INFORMATION PAGE - RENEWAL OF WC 5 94410332 <br />Policy Number From. Policy Period To <br />WC 5 9441x332 09/06/14 09/06/15 <br />Named Insured And Address <br />BARRY A, ROSS APC <br />33 Springwood <br />IRVINE, CA <br />92604 <br />Coverage Is Provided By Agency* <br />FORGE INSURANCE COMPANY 051519410 <br />Agent <br />S&S/WELLS FARGO INSURANCE, INC. <br />AC N9306-130 <br />33 MARQUETTE AVE 13TH FLOOR <br />INNEAPOLIS MN 55402 <br />SCHEDULE <br />PAGE 2 <br />THE FOLLOWING POSTING NOTICE DATA IS INTENDED FOR CNA INTERNAL PROCESSING <br />PURPOSES ONLY <br />TAG FIELD NAME <br />001 <br />002 <br />003 <br />004 <br />005 <br />006 <br />007 <br />008 <br />009 <br />010 <br />011 <br />012 <br />013 <br />014 <br />015 <br />016 <br />017 <br />018 <br />019 <br />EMPLOYER NAME <br />EMPLOYER CITY <br />EMPLOYER STATE <br />EMPLOYER SIP <br />EMPLOYER FEIN <br />INSURANCE CARRIER NAME <br />INSURANCE CARRIER BUREAU CODE <br />INSURANCE CARRIER(OR TPA) NAME <br />POLICY NUMBER <br />POLICY EFFECTIVE DATE <br />POLICY EXPIRATION DATE <br />AGENT NAME <br />AGENT STREET ADDRESS <br />AGENT CITY <br />AGENT STATE <br />AGENT ZIP <br />AGENT PHONE <br />ADJUSTING COMPANY NAME <br />EMPLOYER STREET ADDRESS <br />DATE OF ISSUE: 07/23/14 <br />POLICY ISSUING OFFICE: MINNEAPOLIS <br />FIELD VALUE <br />BARRY A. ROSS APC <br />IRVINE <br />CA <br />092604 <br />2x5752912 <br />VALLEY FORGE INSURANCE COMPANY <br />0046 <br />VALLEY FORGE INSURANCE COMPANY <br />WC 5 94410332 <br />09/06/2014 <br />09/x6/2015 <br />CS&S/WELLS FARGO INSURANCE, INC. <br />733 MARQUETTE AVE 13TH FLOOR <br />MINNEAPOLIS <br />MN <br />055402 <br />866-337-6595 <br />VALLEY FORGE INSURANCE COMPANY <br />33 Springwood <br />INSURED <br />