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1MMPLOVERIT Quotation for Workers' Compensation and Employers Liability Insurance 1� Date:08/16/2017 Applicant/First Named Insured: ALBI Insurance Company: Employers Preferred Insurance Company Underwriting Contact: Lourdes Bussey Underwriter Phone: +1 805 4100781 Underwriter Email: LBUSSEY@EMPLOYERS.COM Quote Number: EIG 2514073-00 Proposed Effective Date: 08/17/2017 Proposed Expiration Date: 08/17/2018 Agency: Harbor West Insurance Agency Inc Agency Number: 2367000 Payment Plan: 100% DP Down Payment: $1,023.00 Installments of: $0.00 EIG Services, Inc. In California, dba EIG Insurance Services We are pleased to offer the fallowing quotation for your workers' compensation insurance. The estimated annual premium is $1,023. This quotation is valid until the Proposed Effective Date noted above. Coverage must be bound prior to the Proposed Effective Date. You may accept this quotation and request policy issuance by selecting Request Blind in the quoting system and making a timely payment. The requested payment plan is based on estimated annual premium (EAP) and is subject to change after policy issuance and final audit. We will send the First Named Insured an invoice when the policy is issued. Please do not make payment from this quotation. This quotation has been prepared based on the information submitted by you and/or your agency. If, prior to binding, the information we received and relied on to generate this quotation changes, we may rescind the existing quote or offer a new quote. A new quote may contain changes in rates, premium, and/or conditions. This quotation and any subsequently issued policy and estimated premium, may also be subject to change based on changes in rates, assessments, bureau promulgated experience modifiers or any other item issued by controlling jurisdictions. This quotation applies solely to the above -referenced First Named Insured and any legally combinable, additionally scheduled Named Insureds listed herein. This quotation is based on submitted information including legal name(s), legal entity type(s), federal tax identification number(s) (FEIN), ownership structure, and the legal combinability of any additionally scheduled Named Insureds. Legal combinability requires the First Named Insured to have majority interest of all additionally scheduled Named Insureds. We are relying upon the accuracy of the information provided. Any irregularity, inaccuracy, or misrepresentation of information may result in modification, cancellation or rescission of a policy issued based upon such information. This quotation is for illustrative purposes only and thus the policy terms and conditions will supersede this quotation. Additionally, the premium calculation details are estimates. The final premium will be determined after the policy ends using the actual, not estimated, payroll/remuneration to calculate the premium basis using the proper classifications and rates that lawfully apply to the business and exposures covered by the policy. This quotation does not amend or otherwise affect the provisions of coverage of any resulting insurance policy issued by Employers Preferred Insurance Company. It is not a representation that coverage does or does not exist for any particular claim or loss under any policy issued. Coverage depends on the applicable provisions of the actual policy issued, the facts and circumstances involved in the claim or loss and any applicable law. (� America's smell business insurance specialist' to1888662-6671 110.,315 PROFESSIONAL CIRCLE I RENO, NV 88521A8021 w ,employerecom 1100 F.IO S804l Inc., an affiliated agency and adjuster NYSE (Employers preferred Insurance Company I Employers Assurance Company Employers Compensation Insurance Company I Employers Insurance Company of Nevada