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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 />WC8804011 <br />Notice to Employees - Injuries Caused By Work <br />WC9900011 <br />Signature/ Copyright <br />WC990002 <br />WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY BUSINESS INSURANCE <br />POLICY <br />WC990005 <br />SCHEDULE OF OPERATIONS <br />WC990069 <br />AMENDATORY ENDORSEMENT - COLORADO <br />WC990301 B <br />WORKERS COMPENSATION BROAD FORM ENDORSEMENT EXTENDED OPTIONS <br />WC990302B <br />WORKERS COMPENSATION BROAD FORM ENDORSEMENT <br />WC990303B <br />WORKERS COMPENSATION BROAD FORM ENDORSEMENT EXTENDED OPTIONS <br />WC990356A <br />AMENDMENT TO WORKERS COMPENSATION BROAD FORM ENDORSEMENT <br />EXTENDED OPTIONS - EMPLOYERS LIABILITY STOP GAP COVERAGE <br />WC990357A <br />AMENDMENT TO WORKERS COMPENSATION BROAD FORM ENDORSEMENT <br />EXTENDED OPTIONS - EMPLOYERS LIABILITY STOP GAP COVERAGE <br />WC990365 <br />EXTENSION OF THE INFORMATION PAGE - ITEM 1 - NAMED INSURED <br />WC990366 <br />EXTENSION OF THE INFORMATION PAGE - ITEM 1 - OTHER WORKPLACES <br />WC990367 <br />EXTENSION OF THE INFORMATION PAGE - ITEM 3.A - STATES COVERED <br />WC990368 <br />EXTENSION OF THE INFORMATION PAGE - ITEM 3.D. - ENDORSEMENTS <br />WC990371A <br />ARIZONA COUNTERSIGNATURE EXCLUSION ENDORSEMENT <br />WC990375 <br />CALIFORNIA INSTALLMENT FEE DISCLOSURE ENDORSEMENT <br />WC990380 <br />WORKERS COMPENSATION BROAD FORM 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 R.WjanagementAnalyst <br />