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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: 30147 <br />Company Code: 9 <br />POLICY NUMBER: 57 WEG ZJ1989 <br />Previous Policy Number: 57 WEG ZJ1989 <br />1. Named Insured and Mailing Address: FEHR & PEERS <br />(No., Street, Town, State, Zip Code) 100 PRINGLE AVE STE 600 <br />WALNUT CREEK CA 94596 <br />FEIN Number: 68-0065540 <br />Suffix <br />LARS RENEWAL <br />6 <br />State Identification Number(s): UIN: UT 7172158 <br />Refer to the EXTENSION OF THE INFORMATION PAGE — WC990365. <br />The Named Insured is: Corporation <br />Business of Named Insured: Architectural Services <br />Other workplaces not shown above: See Endorsement - WC990366 <br />2. Policy Period: From 05/01/22 To 05/01/23 ANNUAL <br />12:01 a.m., Standard time at the insured's mailing address. <br />Producer's Name: INSURANCE OFFICE OF AMERICA INC <br />3875 HOPYARD ROAD SUITE 200 <br />PLEASANTON CA 94588 <br />Producer's Code: 57101972 <br />Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER <br />3600 WISEMAN BLVD <br />SAN ANTONIO TX 78251 <br />(866) 467-8730 <br />Total Estimated Annual Premium: $91,993 <br />Deposit Premium: <br />Policy Minimum Premium: $600 CA (Includes Increased Limit Min. Prem.) <br />Audit Period: ANNUAL Installment Term: Four Pay (30%Down+2@25%+1 @20%) <br />The policy is not binding unless countersigned by our authorized representative. <br />Countersigned by <br />Authorized Representative <br />Form WC 00 00 01 A (1) Printed in U.S.A. <br />Process Date: 03/29/22 <br />03/29/22 <br />Date <br />RAMuaigmadDlMsian <br />E <br />° REVIEWED & APPROVED BY: <br />Pagl °! _ 4+e Aeevdo <br />POlic — �� RfskManagement Specialist <br />