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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 0400 04 <br />(Ed. 7-98) <br />EXTENSION OF INFORMATION PAGE <br />Schedule of Forms <br />ITEM 3D <br />POLICY NO. WC 80946 00 <br />Form <br />Numbers <br />Applicable States <br />WORKERS <br />COMPENSATION <br />FORMS <br />AND ENDORSEMENTS <br />WC <br />04 <br />00 <br />01 <br />B <br />10-14 <br />CA <br />WC INFORMATION PAGE <br />CA <br />WC <br />04 <br />00 <br />05 <br />07-98 <br />CA <br />EXTENSION OF INFORMATION PAGE <br />CA <br />WC <br />00 <br />00 <br />00 <br />C <br />01-15 <br />INSURANCE POLICY <br />CA <br />PN <br />04 <br />99 <br />01 <br />H <br />05-20 <br />CA <br />POLICYHOLDER NOTICE <br />CA <br />PN <br />04 <br />99 <br />02 <br />B <br />05-02 <br />CA <br />WC INSURANCE RATING LAWS <br />CA <br />PN <br />04 <br />99 <br />04 <br />12-01 <br />CA <br />POLICYHOLDER NOTICE - CIGA <br />CA <br />PN <br />04 <br />99 <br />08 <br />12-19 <br />CA <br />POLICYHOLDER NOTICE -ASSEMBLY BILL N05 <br />CA <br />WC <br />00 <br />04 <br />19 <br />01-01 <br />PREMIUM DUE DATE ENDORSEMENT <br />CA <br />WC <br />00 <br />04 <br />21 <br />E <br />01-21 <br />CATASTROPHE (OTHER THAN CERT ACTS) ENDT <br />CA <br />WC <br />00 <br />04 <br />22 <br />C <br />01-21 <br />TERRORISM RISK PGM REAUTH ACT DISCL ENDT <br />CA <br />WC <br />04 <br />03 <br />01 <br />D <br />02-18 <br />CA <br />POLICY AMENDATORY ENDORSEMENT <br />CA <br />WC <br />04 <br />03 <br />10 <br />01-95 <br />CA <br />DUTY TO DEFEND <br />CA <br />WC <br />04 <br />03 <br />60 <br />B <br />01-15 <br />CA <br />EMPLOYERS' LIAB COV AMENDATORY ENDT <br />CA <br />WC <br />04 <br />04 <br />21 <br />01-08 <br />CA <br />OPTIONAL PREMIUM INCREASE ENDORSEMENT <br />CA <br />WC <br />04 <br />04 <br />22 <br />01-12 <br />CA <br />SHORT -RATE CANCELATION ENDORSEMENT <br />CA <br />WC <br />04 <br />06 <br />01 <br />A <br />12-93 <br />CA <br />CANCELATION ENDT <br />CA <br />©1998 by the Workers' Compensation Insurance Rating Bureau of California. All rig Its reserved. <br />From the WCI RB's California Workers' Compensation I nsurance Forms Manual ©2001. <br />HortaN <br />3 z <br />Risk MwagementDMsian <br />REVIEWED & APPROVED BY.- <br />Risk Management Analyst <br />