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QPMJDZ!EFDJTJPOT <br />Qjf!Jotvsbodf!Ipmejoht!Jod/ <br />2126!26ui!Tusffu!OX-!Tvjuf!711 <br />Xbtijohupo-!ED!31116.3716 <br />SBUJOH!XPSLTIFFUT <br />Named Insured:BACKHAUS DANCEDate:09/02/2021 <br />Special Notes:DANCE EDUCATION THROUGH A <br />Agy/Prod Number:1850 <br />Policy Number:WC80946Agy/Prod Name:Automatic Data Processing Insurance Agency, Inc. <br />Client Number:OperatorJSPIVEY <br />System Assign:08209400000000 <br />System Release:21.04 <br />Business Type:Non-Profit <br />Insurance Co:Sirius America Ins Co <br />Line Of Business:Workers Comp (Voluntary) <br />Effective Date:09/07/2021Expiration Date:09/07/2022 <br />Anniversary Date:Audit Frequency:Annual <br />Policy Term:1 Year <br />Predominant State:CA <br />Transaction Type:NEW BUSINESSTransaction Sequence:001 <br />QPMJDZ!QSFNJVN!UPUBMT <br />DpwfsbhftUfsn!Qsfnjvn <br />Dmbtt!Qsfnjvn5-:2:/11 <br />Employer's Liab Premium65.00 <br />Empl Liab Min Diff Premium55.00 <br />Schedule Mod Premium-542.00 <br />Territory Factor984.00 <br />Tuboebse!Qsfnjvn6-592/11 <br />Premium Discount-55.00 <br />Expense Constant160.00 <br />Terrorism34.00 <br />Catastrophe17.00 <br />Ftujnbufe!Qsfnjvn6-748/11 <br />Taxes and Assessments224.00 <br />Ftujnbufe!Upubm6-972/11 <br /> <br />