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POLICYWRITING INDEX <br />CLIENT NUMBER <br />POLICY NUMBER <br />PREVIOUS POLICY NUMBER <br />1 <br />EFFECTIVE DATE <br />1 <br />EXPIRATION DATE <br />1 <br />WC 80946 00 <br />NEW <br />09-07-2021 <br />09-07-2022 <br />NAMEDINSURED BACKHAUS DANCE <br />MISCELLANEOUS INFORMATION <br />TRANSACTION INFORMATION <br />BILL TYPE <br />DIRECT <br />TRANS.TYPE <br />New Business <br />BILL PLAN <br />Monthly <br />TRANS. SEQ. # <br />001 <br />OPERATOR I.D. <br />JSPIVEY <br />DATE PROCESSED <br />09-02-21 <br />PROGRAM CODE <br />TRANS.DATE <br />09-07-21 <br />SIC CODE <br />5812 <br />ENDORSEMENT # <br />RECORD I.D. <br />CANC/REIN REASON <br />FAC REINS <br />LINE OF BUSINESS/ COMMISSIONS: <br />LINE OF BUSINESS COMMISSION % <br />WORKERS' COMPENSATION <br />TERM PREMIUM $ 5,861 <br />BILLED PREMIUM $ 5,861 <br />NAMED INSURED MAILING ADDRESS AGENT INFORMATION CODE 1850 <br />BACKHAUS DANCE Automatic Data Processing Insurance Agency, Inc. <br />1 ADP Boulevard <br />4365 Johanna Ave <br />Lakewood CA 90713-3303 Roseland NJ 07068 <br />ASSEMBLY INFORMATION <br />STAMPS/ STICKERS <br />SPECIAL INSTRUCTIONS <br />MAILING INSTRUCTIONS <br />HortaN RiskMmRgzmentDMsian <br />WCPWN DX1 i R�EWED & APPROVED BY: <br />3 r <br />f R. Vj&wd <br />Risk Management Analyst <br />