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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 li96Kj <br />Company Code: H <br />`$Unix <br />_ LARSRENEWAL <br />L 1 <br />POLICY NUMBER: 76 WED A_L4KRS r <br />Previous Policy Number: New <br />1. Named Insured and Mailing Address: BRIAN PETERSON ART, INC <br />(No., Street, Town, State, Zip Code) 738 N SANTIAGO ST <br />SANTA ANA CA 92701 <br />FEIN Number: 84-3115161 <br />State Identification Number(s): <br />The Named Insured Is: Corporation <br />Business of Named Insured: Fine Arts Schools <br />_ Other workplaces not shown above: 738 N SANTIAGO ST <br />SANTA ANA CA 92701 <br />2. Policy Period: From 04/21/21 To 04/21/22 ANNUAL <br />12:01 a.m., Standard time at the Insured's mailing address. <br />Producer's Name: AP INTEGO INSURANCE GROUP LLC <br />375 WOODCLIFF DRIVE STE 103 <br />FAIRPORT NY 14450 <br />Producer's Code: 76250846 <br />Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER <br />3600 WISEMAN BLVD <br />SAN ANTONIO TX 78251 <br />(877) 287-1316 <br />Total Estimated Annual Premium: $470 <br />Deposit Premium: <br />Policy Minimum Premium: $450 CA <br />Audit Period: ANNUAL Installment Term! <br />The policy is not binding unless countersigned by our authorized representative. <br />Countersigned by Cam e 04/29/21 <br />Authorized Representative Date <br />Form WC 00 00 01 A (1) Printed In U.S.A. Page 1 <br />Process Date: 04/29/21 Policy E aR knn M"entDiAdl <br />a�NREVIEWED & APPRDVEQ BY: <br />a FrM.::t.a � 1E4tl�na�E <br />Rtck Mlnagen MAnalyst <br />