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Page 7 <br />Named Insured BACKHAUS DANCE <br />Customer ID <br />Policy Number WC80946 <br />Transaction Type New Business Effective 9/7/2021 <br />Schedule Modification <br />Date 09/02/2021 <br />Name of Insured <br />BACKHAUS DANCE <br />Special Notes <br />DANCE EDUCATION THROUGH A <br />Policy Number <br />WC80946 <br />Client Number <br />Insurance Co <br />Sirius America Ins Co <br />Line Of Business <br />WK <br />Subline <br />Effective Date <br />09/07/2021 <br />Policy Term <br />1 Year <br />State(s) <br />CA <br />Trans Type <br />New Business <br />Schedule Modification <br />Risk Characteristic <br />Employees -Selection, Training, Supervision <br />Justification <br />Total Mod <br />Agy/Prod Name Automatic Data Processing Insurance Agency, Inc. <br />Operator JACK SPIVEY <br />Expiration Date 09/07/2022 <br />Credit/Debit <br />0.91 <br />FORMAL WRITTEN SAFETY TRAINING IN PLACE <br />0.91 <br />END OF WORKSHEET <br />�oRaN <br />RiskMmRgmerdDMsfan <br />REVIEWED & APPROVED BY. - <br />Risk Management Analyst <br />