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IN REPLY REFER TO: <br />9048876-15 <br />WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY <br />INSURANCE POLICY <br />STATE COMPENSATION INSURANCE FUND <br />Forms and Endorsements Applicable List Policy <br />FORM NUMBER FORM DESCRIPTION <br />10963A <br />ANNUAL RATING ENDORSEMENT <br />10217 <br />2029 -ENDORSEMENT AGREEMENT - <br />CALIFORNIA SHORT -RATE CANCELATION <br />10217 <br />2089 -ENDORSEMENT AGREEMENT - <br />STATUTORY ACCOUNTING PRINCIPLES - BILL RECEIVABLE <br />10217 <br />2437 -ENDORSEMENT AGREEMENT - <br />MEDICAL PROVIDER NETWORK ENDORSEMENT <br />10217 <br />2559A -ENDORSEMENT AGREEMENT - <br />TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION <br />ACT OF 2015 <br />10217 <br />3015 -ENDORSEMENT AGREEMENT - <br />EXECUTIVE OFFICERS - MINIMUM/MAXIMUM LIMITS <br />10610D <br />POLICY HOLDER NOTICE <br />15302 <br />POLICY DIVIDEND DISCLOSURE STATEMENT <br />\�J <br />,GgP�P�t� <br />5880 Owens Dr . Pleasanton, CA 94588-3900 . <br />Mailinq Address: P.O. Box 8192 . Pleasanton, CA 94588-8792 <br />