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INFORMATION PAGE (Continued) <br />Policy Number: 76 WEG AL4KRS <br />1 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 verifica#Ion and chance by audit. <br />Premium Basis_....,__ <br />Classifications Total Estimated Rates Per Estimated <br />Code Number and Annual $too of Annual <br />Description Remuneration Remuneration Premium <br />Total Standard Premium <br />Expense Constant <br />Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement <br />Estimated Annual Premium (before Surcharges) <br />Total Estimated Surcharges <br />*See the attached Schedule(s) of Operations for Location and State Level Premium Information <br />Total Estimated Annual Premium: $470 <br />Deposit Premium: <br />Policy Minimum Premium: $450 CA <br />Interstate/intrastate Identification Number: Refer to Schedule of Operations <br />NAICS: 611610 <br />Labor Contractors Policy Number: SIC: 5231 <br />Form WC 00 00 01 A (1) Printed in U.S.A. Page 2 <br />Process Date: 04/29/21 Policy Expiration Dal <br />$250 <br />$200 <br />$3 <br />$453 <br />$17 <br />RN <br />en,.,p wekMcnagementDivisan <br />♦ REVIEWED&APPROVED BY: <br />s y rwnc+.rri�c �, (it�anae�t <br />Rbk Management Analyst <br />a <br />