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WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY <br />INFORMATION PAGE <br />POLICY NO. 92-GO-D366-6 COVERAGE IS PROVIDED BY 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 <br />SANTANA, LUCIA <br />DBA RELAMPAGO DEL CIELO <br />PO BOX 3158 <br />SANTA ANA CA 92703-0158 <br />NCCI CARRIER CODE NO. 14842 <br />FEIN 953083493 <br />LOCATION: <br />600 W SANTA ANA BLVD STE 214A <br />SANTA ANA CA 92701-4558 <br />INSURED IS AN INDIVIDUAL <br />COPYRIGHT 1987 NATIONAL COUNCIL ON COMPENSATION INSURANCE <br />----------------------------------------------------------------------------- <br />2. THE POLICY PERIOD IS FROM 07/01/2021 TO 07/01/2022 12:01 A.M. STANDARD T: <br />AT THE INSURED'S MAILING ADDRESS. <br />----------------------------------------------------------------------------- <br />3A. WORKERS COMPENSATION INSURANCE: PART ONE OF THE POLICY APPLIES TO THE <br />WORKERS COMPENSATION LAW OF THE STATES LISTED HERE: CA <br />B. EMPLOYERS LIABILITY INSURANCE: PART TWO OF THE POLICY APPLIES TO <br />WORK IN EACH STATE LISTED IN ITEM 3A. THE LIMITS OF OUR LIABILITY <br />UNDER PART TWO ARE: BODILY INJURY BY ACCIDENT $1,000,000 EACH ACCIDENT <br />BODILY INJURY BY DISEASE $1,000,000 EACH EMPLOYEE <br />BODILY INJURY BY DISEASE $1,000,000 POLICY LIMIT <br />C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO ALL STATES <br />EXCEPT ME, MT, ND, OH, RI, WA, WV, WY AND STATES LISTED IN 3A. <br />D. THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES: WCOOOOOOC <br />WC040360A WC040301D WC040601A WC000422C* WC000421E* WC040421* <br />*EFFECTIVE 07/01/ <br />-------------------------------------- --------------------------------------- <br />4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF <br />RULES, CLASSIFICATIONS, RATES AND RATING PLANS. ALL INFORMATION <br />REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. <br />----------------------------------------------------------------------------- <br />PREMIUM BASIS TO- RATE/$100 ESTIMATE <br />CODE NOS. AND TAL ESTIMATED AN- REMUNERA- ANNUAL <br />CLASSIFICATIONS NUAL REMUNERATION TION PREMIUM <br />-------------------------------------------------------------------------- <br />8810 72,832 .40 29 <br />CLERICAL OFFICE EMPLOYEES - NOC <br />8868 <br />COLLEGES OR SCHOOLS - PRIVATE - NOT <br />AUTOMOBILE SCHOOLS - PROFESSORS, <br />TEACHERS OR PROFESSIONAL EMPLOYEES <br />COMPANY SURCHARGE FOR INCREASED <br />EMPLOYERS LIABILITY LIMITS <br />PREMIUM ADJUSTMENT REQUIRED <br />FOR MINIMUM PREMIUM <br />TERRORISM 9740 <br />M <br />72,932 <br />1.10 <br />.03 <br />20i <br />2: <br />MINIMUM PREMIUM $ 500 CALIFORNIA TOTAL ESTIMATED ANNUAL"PREMIUM $(MIN.) 63, <br />------------------------------------------------------------------------------ <br />PREMIUM ADJUSTMENT PERIOD SHALL BE MONTHLY DEPOSIT PREMIUM $ 6' <br />STATE FRAUD SURCHARGE $ 3.0( <br />SEE SURCHARGE OVERFLOW PAGE <br />PREPARED 05/07/2021 <br />WC 00 00 01 04-84 COUNTERSIGNED <br />ortaN RAMmWmerdDMafan <br />REVIEWED & APPROVED BY.- <br />' <br />Risk Management Analyst <br />