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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 00 05 <br />(Ed. 7-98) <br />EXTENSION OF INFORMATION PAGE <br />Classifications <br />ITEM 4 <br />POLICY NO. WC 80946 00 <br />Premium Basis Rate Per $100 Estimated <br />Code Estimated Annual of Annual <br />No. Classifications Remuneration Remuneration Premium <br />0001-01 BACKHAUS DANCE <br />FEIN # 05-0575068 <br />SIC CODE 5812 <br />NAICS CODE 711110 <br />CA ERN ## 1111 <br />4365 Johanna Ave <br />Lakewood CA 90713-3303 <br />9156 Theaters - Dance/Opera $ 86,005 5.72 $ 4,919.00 <br />Copyright 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. <br />From the WCIRB's California Workers' Compensation Insurance Forms Manual Copyright 2001. <br />�oRaN <br />r <br />RiskMwaganedDivisian <br />REVIEWED & APPROVED BY.- <br />p P. Vj&,Vd <br />Risk Management Analyst <br />