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(Policy Provisions: WCOOOOOOC) <br />INFORMATION PAGE <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY <br />INSURER: SEE ATTACHED ENDORSEMENT <br />NCCI Company Number: 14397 <br />Company Code: 9 <br />POLICY NUMBER: 59 WEC AC9055 <br />Previous Policy Number: 59 WEC AC9055 <br />1. Named Insured and Mailing Address: BAY SPROUTS LLC <br />(No., Street, Town, State, Zip Code) 655 S MAIN ST STE 200-317 <br />ORANGE CA 92868 <br />FEIN Number: 46-2577161 <br />Suffix <br />LARS RENEWAL <br />2 <br />State Identification Number(s): Refer to the EXTENSION OF THE INFORMATION PAGE — WC990365. <br />The Named Insured is: LLC <br />Business of Named Insured: Full -Service Restaurants <br />Other workplaces not shown above: See Endorsement - WC990366 <br />2. Policy Period: From 07/03/20 To 07/03/21 ANNUAL <br />12:01 a.m., Standard time at the insured's mailing address. <br />Producer's Name: FIRSTMARK INSURANCE GROUP INC <br />210 5TH AVENUE SOUTH STE 203 <br />EDMONDS WA 98020 <br />Producer's Code: 59305815 <br />Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER <br />3600 WISEMAN BLVD <br />SAN ANTONIO TX 78251 <br />(877) 287-1316 <br />Total Estimated Annual Premium: $71,141 <br />Deposit Premium: <br />Policy Minimum Premium: $1,150 NC (Includes Increased Limit Min. Prem.) <br />Audit Period: ANNUAL Installment Term: <br />The policy is not binding unless countersigned by our authorized representative. <br />Countersigned by �G`® �> 05/25/20 <br />Authorized Representative Date <br />J�N <br />IZAMmWmentDMsion <br />REVIEWED & APPROVED BY. - <br />Form WC 00 00 01 A (1) Printed in U.S.A. Page VI <br />Process Date: 05/25/20 Policy --_ Wsk Pjanagement Analpt <br />