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INSURER: STATE COMPENSATION INSURANCE FUND <br />BROKERAGE: N/A <br />POLICY NO. 9048876-15 <br />DATE: June 26, 2015 <br />PAGE 1 OF 4 <br />CALIFORNIA WORKERS' COMPENSATION INSURANCE <br />Policyholder Dividend Disclosure Statement <br />FRIENDS OF SANTA ANA ZOO <br />1801 E CHESTNUT AVE <br />SANTA ANA, CA 92701 <br />EMPLOYERIINSURED: FRIENDS OF SANTA ANA Z00 <br />EFFECTIVE DATE: July 1, 2015 <br />ESTIMATED ANNUAL PREMIUM: $24,706.00 <br />ESTIMATED DIVIDEND PLAN PREMIUM: $24,706.00 <br />TERM OF DIVIDEND PLAN: ONE YEAR <br />Workers' compensation insurers are authorized to issue participating policies. A dividend <br />(refund) under such a policy can only be paid from surplus accumulated from premiums on <br />workers' compensation policies issued pursuant to the laws of California. <br />Under California law it is unlawful for an insurer to promise the future payment of dividends <br />under an unexpired workers' compensation policy or to misrepresent the conditions for <br />dividend payment. Dividends are payable only pursuant to conditions determined by the <br />Board of Directors of the State Compensation Insurance Fund following policy expiration. <br />It is a misdemeanor for any insurer or officer or agent thereof, or any insurance broker <br />or solicitor, to promise the payment of future workers' compensation dividends. Past <br />dividend performance is no guarantee of an insurer's future dividend performance. <br />PART I: HISTORICAL DISCLOSURE <br />This dividend statement is based on the most recent dividend <br />declaration by our Board of Directors for policyholders with <br />characteristics similar to yours and a dividend plan premium <br />of $24,706.00. This declaration applied to policies <br />whose term of coverage began January 1, 2014 to <br />December 31, 2014 and whose term of coverage ended during the <br />period January 1, 2015 to December 31, 2015. <br />The dividend formula was: <br />Dividend = Estimated Annual Premium X 2.6% <br />2.6% is the percentage factor set by the Board of Directors d ��• <br />for the 2014 policy year. Ov,eNJO <br />C, <br />K: ' evas <br />16302 (04- 2015) <br />