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•C 1I�� �. <br />p1 :, <br />Workers Cor ration and Employers Liability <br />Insurance Pon_, <br />I/ii9 'IWC <br />Policy Number Policy Period <br />3 HUTTON CENTRE DRIVE STE 550 <br />Fro To <br />--_..» <br />SANTA ANA, CA 92707-8724 <br />_ <br />NCV 5900420 11/01/201711/01/2018 <br />_ <br />12:Ot A.M. SWntlard Time at the tlascribetl location <br />� Eit <br />Transaction <br />INFORMATION PAGE <br />Named Insured and Address <br />}�ivNUAL <br />STATE: California <br />Agent <br />DELHI COMMUNITY CENTER <br />505 E CENTRAL AVE <br />R -T SPECIALTY LLC DBA R -T SPEC <br />SANTA ANA CA 92707 <br />99,840 <br />IALTY INS SVCS LLC <br />839 <br />CLERICAL OFFICE EMPLOYEES <br />500 S GRAND AVE SUITE 2100 <br />350,420 <br />0.66000 <br />LOS ANGELES CA 90071 <br />MARGARITAS^DELHI CENTER. ORO <br />8868 <br />Telephone: 888-782-9887 <br />7..62000 <br />5032699 <br />SCHEDULE OF CLASSIFICATIONS! <br />t f � <br />yq <br />yy <br />�rSHTSTI�+iSTCp <br />d Y <br />WOW <br />1ATTIO <br />� Eit <br />}�ivNUAL <br />STATE: California <br />SALESPERSONS -OUTSIDE <br />8742 <br />99,840 <br />0.84000 <br />839 <br />CLERICAL OFFICE EMPLOYEES <br />8810 <br />350,420 <br />0.66000 <br />2,313 <br />SCHOOLS AND INSTRUCTIONAL PROGRAMS - PRIVATE - BOO <br />8868 <br />7..62000 <br />SCHOOLS AND INSTRUCTIONAL PROGRAMS - PRIVATE - HOC <br />9101 <br />37,232 <br />9.55000 <br />3,556 <br />Subtotal State Premium <br />$ <br />6,708 <br />EXPENSE CONSTANT <br />0900 <br />WAIVER OF OUR RIGHT TO RECOVER <br />0930 <br />300 <br />TERRORISM <br />9740 <br />487,492 <br />1.00000 <br />0.02000 <br />100 <br />CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORIS <br />9741 <br />487,492 <br />0.02000 <br />97 <br />SCHEDULE DEBIT <br />9889 <br />6,808 <br />1.37000 <br />97 <br />2,519 <br />CALIFORNIA WORKERS COMPENSATION FRAUD ASSESSMENT F <br />CA AST <br />9,485 <br />1.00167 <br />CA LABOR ENFORCEMENT & COMPLIANCE FUND <br />CA LEC <br />9,485 <br />1.00191 <br />16 <br />CALIFORNIA OCCUPATIONAL SAFETY & HEALTH FUND <br />CA OSH <br />9,485 <br />1.00230 <br />18 <br />CALIFORNIA SUBSEQUENT INJURIES BENEFITS TRUST FUND <br />CA SIH <br />9,485 <br />1.00133 <br />22 <br />CALIFORNIA USER FUNDING SURCHARGE <br />CA SRG <br />9,485 <br />1.00312 <br />13 <br />CALIFORNIA UNINSURED EMPLOYERS BENEFIT TRUST FUND <br />CA UEE <br />9,485 <br />30 <br />CALIFORNIA INSURANCE GUARANTEE ASSOCIATION SURCHAR <br />CIGAS <br />9,485 <br />1.00072 <br />1.02000 <br />7 <br />COMMISSION ADJUSTMENT MODIFIER <br />SAAJC <br />9,327 <br />0.96400 <br />190 <br />Total State Premium <br />- 336 <br />$ 9 781 <br />Total Fetimatari Pr.mix.m <br />INSURED COPY <br />WC000007A 0588 Printed on 11/02/2017 Page 2 of 4 <br />