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TRAVELERS) <br />ONE TOWER SQUARE <br />HARTFORD CT 06183 <br />WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />TYPE V INFORMATION PAGE WC 00 00 01 ( A) <br />POLICY NUMBER: UB-OR3408OA-20-42-G <br />REWRITING UB-BP528867-20-42-G <br />INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA <br />1 NCCI CO CODE: 13579 <br />INSURED: PRODUCER: <br />THE FRIDA CINEMA METRO COAST INS SRVC LLC <br />305 E 4TH ST 25950 ACERO STE 345 <br />STE 100 MISSION VIEJO, CA 92691 <br />SANTA ANA, CA 92701 <br />Insured is A CORPORATION <br />Other work places and identification numbers are shown in the schedule(s) attached. <br />2. The policy period is from 03-25-20 to 03-25-21 12:01 A.M. at the insured's mailing address. <br />3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers <br />Compensation Law of the state(s) listed here: <br />CA <br />B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in <br />item 3.A. The limits of our liability under Part Two are: <br />Bodily Injury by Accident: <br />$ <br />1,000,000 <br />Each Accident <br />Bodily Injury by Disease: <br />$ <br />1,000,000 <br />policy Limit <br />Bodily Injury by Disease: <br />$ <br />1,000,000 <br />Each Employee <br />C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: <br />AL AR AZ CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA ND ME MI MN <br />MO MS MT NC WE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI <br />WV <br />D. This policy includes these endorsements and schedules: <br />SEE LISTING OF <br />- EXTENSION OF INFO PAGE <br />4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating <br />Plans. All required information is subject to verification and change by audit to be made ANNUALLY <br />DATE OFISSUE: 05-11-20 JW <br />OFFICE: BREA/LA/ORANGE CA 189 <br />PRODUCER: METRO COAST INS SRVC LLC DPG66 <br />..� MakManage""d DMsim <br />y,`g \� RtviE SAPPROVm BY: <br />® Rbk Management Maly t <br />