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EXTENSION OF THE INFORMATION PAGE - ITEM 3.A - STATES COVERED <br />Policy Number: 59 WEC AC9055 Endorsement Number: <br />Effective Date: 07/03/20 Effective hour is the same as stated on the Information Page of the policy. <br />Named Insured and Address: BAY SPROUTS LLC <br />655 S MAIN ST STE 200-317 <br />ORANGE CA 92868 <br />Item 3.A. of the Information Page is completed to include the following states: <br />Wisconsin <br />WI <br />North Carolina <br />NC <br />California <br />CA <br />Arizona <br />AZ <br />Illinois <br />IL <br />Colorado <br />CO <br />Form WC 99 03 67 Printed in U.S.A. <br />Process Date: 05/25/20 <br />ew cF RAMwagementDMsian <br />Jy/\'x REVIEWED & APPROVED BY.- <br />V"° <br />Policy E _� RFskPjanagementAnalpt <br />