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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 />WC040301 BB <br />POLICY AMENDATORY ENDORSEMENT - CALIFORNIA <br />WC040306 <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - <br />CALIFORNIA <br />WC040360B <br />EMPLOYERS LIABILITY COVERAGE AMENDATORY ENDORSEMENT - CALIFORNIA <br />WC040421 <br />OPTIONAL PREMIUM INCREASE ENDORSEMENT - CALIFORNIA <br />WC040422 <br />CALIFORNIA SHORT -RATE CANCELLATION ENDORSEMENT <br />WC040601A <br />CALIFORNIA CANCELLATION ENDORSEMENT <br />WC050402 <br />COLORADO CLASSIFICATION ENDORSEMENT <br />WC050403 <br />COLORADO PREMIUM CREDIT FOR CERTIFIED RISK MANAGEMENT PROGRAMS <br />ENDORSEMENT <br />WC120306A <br />ILLINOIS WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE <br />POLICY EXCLUSION ENDORSEMENT <br />WC120601 F <br />ILLINOIS AMENDATORY ENDORSEMENT <br />WC120603 <br />ILLINOIS RENEWAL ENDORSEMENT <br />WC320301 D <br />NORTH CAROLINA AMENDED COVERAGE ENDORSEMENT <br />WC480601 C <br />WISCONSIN LAW ENDORSEMENT <br />WC480603B <br />FOREIGN COVERAGE ENDORSEMENT <br />WC480606B <br />WISCONSIN CANCELLATION AND NONRENEWAL ENDORSEMENT <br />WC550011 D <br />Employees Claim for Workers compensation Benefits <br />WC8804001 <br />Notice to Employees - Injuries Caused By Work (TITLE IN SPANISH) <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 R.WjanagementAnalyst <br />