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Page 4 <br />Named InsuredBACKHAUS DANCE <br />Customer ID <br />Policy NumberWC80946 <br />Transaction TypeNew BusinessEffective9/7/2021 <br /> <br />XPSLFST!DPNQ!QPMJDZ!JOGPSNBUJPO!SFDBQ <br />Predominant State:CA <br />Employers Liability:Each Accident:1,000,000 <br />Policy Limit:1,000,000 <br />Each Employee:1,000,000 <br />Admiralty Limit:Per Accident:N/A <br />Program Type:N/A <br />FELA Limit:Per Accident:N/A <br />Program Type:N/A <br />Retro Plan:No <br />Interstate Exper Mod ID: <br />Effective Date: <br />Exper Mod: <br />Njojnvn!QsfnjvnUfsn0UsbotIjhiftu!Qfs!Qpmjdz <br />Policy:15901590 <br />Empl Liab:120120 <br />Admiralty: <br />FELA: <br />Combined Policy Premium: <br />NJ Premium: <br />Executive Officers:No <br />Employee Leasing:No <br />Deposit Factor: <br />Installment Plan:11 <br /> <br />