Laserfiche WebLink
EXTENSION OF THE INFORMATION PAGE - ITEM 3.13 - ENDORSEMENTS <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.D. of the Information Page is completed to include the following endorsements: <br />G-4119-0 POLICYHOLDER NOTICE -PAYROLL BILLING <br />WC000000C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC000001A.1 INFORMATION PAGE <br />WC000001A.2 INFORMATION PAGE <br />WC000115 NOTIFICATION ENDORSEMENT OF PENDING LAW CHANGE TO TERRORISM RISK <br />INSURANCE PROGRAM REAUTHORIZATION ACT OF 2015 <br />WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION ENDORSEMENT <br />WC000313 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <br />WC000403 EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT <br />WC000406 Premium Discount Endorsement <br />WC000406A <br />PREMIUM DISCOUNT ENDORSEMENT <br />WC000414A <br />90-DAY REPORTING REQUIREMENT- NOTIFICATION OF CHANGE IN OWNERSHIP <br />ENDORSEMENT <br />WC000419 <br />PREMIUM DUE DATE ENDORSEMENT <br />WC000421 D <br />CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM <br />ENDORSEMENT <br />WC000422B <br />TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE <br />ENDORSEMENT <br />WC000424 <br />AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT <br />WCO20401 C <br />ARIZONA ALCOHOL AND DRUG -FREE WORKPLACE PREMIUM CREDIT <br />ENDORSEMENT <br />WCO20601A <br />ARIZONA CANCELLATION ENDORSEMENT <br />Form WC 99 03 68 Printed in U.S.A. <br />Process Date: 05/25/20 <br />ew cF RAMwagementDMsian <br />Jy/\'x REVIEWED & APPROVED BY.- <br />v <br />POIIC WskPjanagementAnalyst <br />