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HOME OFFICE SAN FRANCISCO ANNUAL RATING ENDORSEMENT <br />IT IS AGREED THAT THE CLASSIFICATIONS AND RATES PER $100 OF REMUNERATION APPEARING <br />IN THE CONTINUOUS POLICY ISSUED TO THIS EMPLOYER ARE AMENDED AS SHOWN BELOW. <br />CONTINUOUS POLICY 9048876-21 <br />IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT YOUR LOCAL STATE FUND OFFICE BELOW: <br />SPECIALTY OPERATIONS <br />PO BOX 11911 <br />SANTA ANA CA 92711 <br />(925) 523-5199 <br />Nothing herein contained shall be held to vary, alter, waive or extend any of the terms, conditions <br />agreements or limitations of the Policy other than as herein stated. <br />When countersigned by a duly authorized officer or representative of the State Compensation Insurance <br />Fund, these declarations shall be valid and form part of the Policy. <br />AUTHORIZED REPRESENTATIVE <br />PRESIDENT AND CEO <br />;OUNTERSIGNED AND ISSUED AT SAN FRANCISCO JUNE 25, 2021 <br />SCIF FORM 10963A (REV.7-2014) <br />�oRaN <br />3 <br />RAManagementDiwalan <br />REVIEWED & APPROVED BY.- <br />z <br />a <br />F JZ. V <br />Risk Management Analyst <br />