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(Policy Provisions: WCOOOOOOC) <br />INFORMATION PAGE <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY <br />INSURER: Trumbull Insurance Company <br />ONE HARTFORD PLAZA HARTFORD CT 06155 <br />NCCI Company Number: 19666 <br />Company Code: H <br />v <br />�, <br />fbMFORD <br />Suffix <br />LARS RENEWAL <br />POLICY NUMBER: 172WECABIZ5Q �3 <br />Previous Policy Number: 72 WEC AB1Z5Q <br />1. Named Insured and Mailing Address: AEF SYSTEMS CONSULTING INC <br />(No., Street, Town, State, Zip Code) 8502 E CHAPMAN AVE STE 376 <br />ORANGE CA 92869 <br />FEIN Number: 33-0498282 <br />State Identification Number(s): <br />The Named Insured is: Corporation <br />Business of Named Insured: Computer Systems Design Services <br />Other workplaces not shown above: 8502 E CHAPMAN AVE STE 376 <br />ORANGE CA 92869 <br />2. Policy Period: From 02/01/20 To 02/01/21 ANNUAL <br />12:01 a.m., Standard time at the insured's mailing address. <br />Producer's Name: AJ GALLAGHER & CO INS BRKERS OF CA <br />505 N BRAND BLVD STE 600 <br />GLENDALE CA 91203 <br />Producer's Code: 72250878 <br />Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER <br />3600 WISEMAN BLVD <br />SAN ANTONIO TX 78251 <br />(8771853-2582 <br />Total Estimated Annual Premium: $880 <br />Deposit Premium: <br />Policy Minimum Premium: $600 CA <br />Audit Period: ANNUAL Installment Term: Ten Pay (25%Down+9@8.33%) <br />The policy is not binding unless countersigned by our authorized representative. <br />Countersigned by Of <br />Authorized Representative <br />Form WC 00 00 01 A (1) Printed in U.S.A. Page <br />Process Date: 12/23/19 Policy <br />12/23/19 <br />RiskidwagmiadDiVULDn <br />env Arrrtav® <br />Rkk Management Analyst <br />