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INFORMATION PAGE (Continued) <br />Policy Number: 76 V/EG AL4KRS <br />3 A. Workers Compensation Insurance: Pan one of the policy applies to the Workers Compensation Law of the states <br />listed here CA <br />Employers Liability Insurance: Pan Two of the policy applies to work in each state listed in Item 3 A <br />The limits of our liability under Pan 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 S1,000,000 each employee <br />C. Other States Insurance: Part Three of the policy applies to the slates, if any , listed here. <br />ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WYOMING, U.&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 change 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 <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 />Labor Contractors Policy Number: <br />Form WC 00 00 01 A (1) Printed in U.S.A. <br />Process Date: 04/29/21 <br />NAICS: 611610 <br />SIC:5231 <br />$250 <br />$200 <br />S3 <br />$453 <br />S17 <br />Paget <br />f.`r+roa <br />nreawrn er. <br />Policy Expiration Dat <br />RohFNr,age,nrn Omei�Ai°e <br />00 <br />