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INFORMATION PAGE (Continued) <br />Policy Number: 72 WEC AB1Z5Q <br />3.A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the states <br />listed here: CA <br />B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. <br />The limits of our liability under Part Two are: <br />Bodily injury by Accident $1,000,000 each accident <br />Bodily injury by Disease $1,000,000 policy limit <br />Bodily injury by Disease $1,000,000 each employee <br />C. Other States Insurance: Part Three of the policy applies to the states, if any , listed here: <br />ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WYOMING, U.S.TERRITORIES AND STATES <br />DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE. <br />D. This policy includes these endorsements and schedule: <br />SEE ENDORSEMENT -WC 99 03 68 <br />4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating <br />Plans. All information required below is subject to verification and chanoe by audit. <br />Premium Basis <br />Classifications Total Estimated Rates Per Estimated <br />Code Number and Annual $100 of Annual <br />Description Remuneration Remuneration Premium <br />Total Standard Premium $650 <br />Expense Constant $200 <br />Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement $1 <br />Estimated Annual Premium (before Surcharges) $851 <br />Total Estimated Surcharges $29 <br />*See the attached Schedule(s) of Operations for Location and State Level Premium Information <br />Total Estimated Annual Premium: $880 <br />Deposit Premium: <br />Policy Minimum Premium: $600 CA <br />Interstate/Intrastate Identification Number: Refer to Schedule of Operations <br />Labor Contractors Policy Number: <br />Form WC 00 00 01 A (1) Printed in U.S.A. <br />Process Date: 12/23/19 <br />NAICS: 541512 <br />SIC:7379 <br />Page 2 F4.� z vsmruL <br />Policy Expiratil Risk Management MatyH <br />