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WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY <br />CLAIM KIT NOTICE <br />POLICY N0. 92-GO-D366-6 23-2463-FAC1 <br />REPLACES NO. 92-GP-W913-4 STATE FARM FIRE AND CASUALTY COMPANY <br />PO Box 853925, Richardson TX 75085-3925 <br />NAMED INSURED & MAILING ADDRESS: Digitally signed by <br />SANTANA, LUCIA Francine FrancineR. <br />DBA RELAMPAGO DEL CIELO Villareal <br />PO BOX 3158 R. Villareal Date:2021.07.08 <br />SANTA ANA CA 92703-0158 07:56:36-07'00' <br />Thank you for allowing State Farm®to provide your business with Workers' <br />Compensation Insurance. To help you remain compliant with your state(s) regulations, <br />required posters have been made available to you through www.statefarm.com® It is <br />YOUR RESPONSIBILITY TO POST this information as required by the state(s) in <br />which you conduct business. <br />To download and print your required postings: <br />1. Go to www.stB.fm/claimkit <br />2. Scroll to locate the State(s) you operate in and selectthe link <br />The information on the right side of the page includes state required bulletins and posters <br />which need to be Arinted and is Ip,�yid in your place of business. <br />In addition, while we hope you never experience a workplace injury, we want you to be <br />prepared in the eventyou need to report a claim. You can also download and printthe <br />First Report of Injury document from the same web page. <br />On the right side of the page you will locate the 'First Report of Injury; which is <br />YOUR RESPONSIBILITY TO USE TO NOTIFY US OF ALL EMPLOYEE <br />INJURIES as soon as the injury occurs. In addition, the information on the left side of <br />the page is what you will need when reporting a claim, including phone and fax numbers <br />and mailing address. <br />If you do not have access to the internet or the abilityto print the required posters, <br />please contact your State Farm agent or call 1-855-264-2229 for a claims kit to be <br />mailed to you. <br />Again, we thank you for choosing State Farm to provide your business with Workers' <br />Compensation Insurance. <br />Prepared 05/07/2021 597-633.312-13-20191F0303D1 <br />©Copyright, State Farm Mutual Automobile Insurance Company, 2008 <br />Includes copyrighted material of Insurance Services Office, Inc., with its permission. <br />ortaN <br />i , <br />Risk MwagmertLDWisian <br />REVIEWED & APPROVED BY.- <br />cc <br />Risk Management Analyst <br />