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POLICYWRITING INDEX <br />ACCOUNT NUMBER I POLICY NUMBER I PREVIOUS POLICY NUMBER I EFFECTIVE DATE - EXPIRATION DATE <br />I WC 80946 00 1 NEW 1 09-07-2021 09-07-2022 1 <br />COMPUTER PRODUCED FORMS <br />WC <br />04 <br />00 <br />01 <br />B <br />10-14 <br />CA WC INFORMATION PAGE <br />WC <br />04 <br />00 <br />05 <br />07-98 <br />CA EXTENSION OF INFORMATION PAGE <br />WC <br />00 <br />00 <br />00 <br />C <br />01-15 <br />INSURANCE POLICY <br />PN <br />04 <br />99 <br />01 <br />H <br />05-20 <br />CA POLICYHOLDER NOTICE <br />PN <br />04 <br />99 <br />02 <br />B <br />05-02 <br />CA WC INSURANCE RATING LAWS <br />PN <br />04 <br />99 <br />04 <br />12-01 <br />CA POLICYHOLDER NOTICE — CIGA <br />PN <br />04 <br />99 <br />08 <br />12-19 <br />CA POLICYHOLDER NOTICE —ASSEMBLY BILL N05 <br />WC <br />00 <br />04 <br />19 <br />01-01 <br />PREMIUM DUE DATE ENDORSEMENT <br />WC <br />00 <br />04 <br />21 <br />E <br />01-21 <br />CATASTROPHE (OTHER THAN CERT ACTS) ENDT <br />WC <br />00 <br />04 <br />22 <br />C <br />01-21 <br />TERRORISM RISK PGM REAUTH ACT DISCL ENDT <br />WC <br />04 <br />03 <br />01 <br />D <br />02-18 <br />CA POLICY AMENDATORY ENDORSEMENT <br />WC <br />04 <br />03 <br />10 <br />01-95 <br />CA DUTY TO DEFEND <br />WC <br />04 <br />03 <br />60 <br />B <br />01-15 <br />CA EMPLOYERS' LIAB COV AMENDATORY ENDT <br />WC <br />04 <br />04 <br />21 <br />01-08 <br />CA OPTIONAL PREMIUM INCREASE ENDORSEMENT <br />WC <br />04 <br />04 <br />22 <br />01-12 <br />CA SHORT —RATE CANCELATION ENDORSEMENT <br />WC <br />04 <br />06 <br />01 <br />A <br />12-93 <br />CA CANCELATION ENDT <br />�oRaN <br />} r <br />RiskMmWmentDMsiun <br />REVIEWED & APPROVED BY.- <br />cc <br />r6+" R. vj&wd <br />Risk Management Analyst <br />