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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />INFORMATION PAGE <br />Sirius America Ins Co <br />Insurer ID No(s). 28363 <br />1. Named Insured: BACKHAUS DANCE <br />Mailing Address: 4365 Johanna Ave <br />Lakewood CA 90713-3303 <br />Policy No. <br />WC 80946 00 <br />Prior Policy No. <br />0 <br />Individual <br />Corporation <br />Partnership <br />LLC <br />LLP <br />WC 04 00 01 B <br />(Ed. 10-14) <br />Email Address: KIM@BACKHAUSDANCE . ORG 0 Other: <br />FEIN: 050575068 Non -Profit <br />Intra/Interstate Risk ID No. <br />Other workplaces not shown above: See Schedule of Locations <br />2. The policy period is from 09-07-2021to 09-07-2022 12:01 A.M. standard time at the insured's mailing address. <br />3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed <br />here: <br />CA <br />B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3A. The limits of our <br />liability under Part Two are: <br />Bodily Injury by Accident $ 1,000,000 each accident <br />Bodily Injury by Disease $ 1,000,000 policy limit <br />Bodily Injury by Disease $ 1,000,000 each employee <br />C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: <br />AK AZ AR CO DE DC FL GA IL IN IA KS KY LA MD MI MS MO NE NV <br />NH NJ NM NY NC OK PA RI SC TN TX UT VT VA WV WI <br />D. This policy includes these endorsements and schedules: <br />See Schedule of Forms and Endorsements <br />4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All <br />information required below is subject to verification and change by audit. <br />Premium Basis Rate Per Estimated <br />Code Estimated Annual $100 of Annual <br />No. Classifications Remuneration Remuneration Premium <br />See Extension of Information Page <br />Experience Modification See Extension of Information Page Total Estimated Annual Premium $ 5,861 <br />Minimum Premium $ 1,590 Deposit Premium $ 978 <br />Premium Adjustment Period: Annual Countersigned B <br />Producer Information: Automatic Data Processing Insurance Agency;—inc. <br />Servicing/Issuing Office 1015 15th Street NW, Suite 600, Washington, DC 20005-2605 <br />Date <br />Copyright 2014 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. <br />From the WCIRB's California Workers' Compensation Insurance Forms Manual Copyright 2014. <br />�oRaN <br />r� -:. ^ecoG< <br />4r <br />of <br />Risk ManagemedDiviaiun <br />REVIEWED & APPROVED BY.- <br />p L" PZ. v� <br />Risk Management Analyst <br />