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TRAVELERS <br />ONE TOWER SQUARE <br />HARTFORD CT 06183 <br />CLASSIFICATION SCHEDULE: <br />CLASSIFICATIONS <br />SIC -CODE: 6512 <br />CODE NO <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 />PREMIUM BASIS <br />ESTIMATED RATES ESTIMATED <br />TOTAL ANNUAL PER $100 OF ANNUAL <br />REMUNERATION REMUNERATION PREMIUM <br />SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(S) <br />NAICS: 531120 <br />STANDARD <br />TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 3759 <br />PREMIUM DISCOUNT NONE <br />0900-04 EXPENSE CONSTANT 160 <br />TERRORISM 40 <br />TOTAL ESTIMATED PREMIUM 3959 <br />TAXES AND SURCHARGES 134 <br />DEPOSIT AMOUNT DUE 4093 <br />Minimum Premium: $ 500 <br />DATE OF ISSUE: 05-11-20 JW <br />OFFICE: BREA/LA/ORANGE CA 189 <br />PRODUCER: METRO COAST INS SRVC LLC DPG66 <br />COUNTE <br />Riele Managnnait Dnisian <br />REVIEWED & APPROYm BY: <br />�. <br />® R¢k klanagement Analyst <br />