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INFORMATION PAGE (Continued) <br />Policy Number. 76 WEG AL4KRS <br />3 A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the slates <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 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 />NAICS: 611610 <br />Labor Contractors Policy Number: SIC: 5231 <br />Form WC 00 00 01 A (1) Printed in U.S.A. <br />Process Date: 04/29/21 <br />S250 <br />$200 <br />$3 <br />$453 <br />$17 <br />g b. <br />R1@4Mmvgar4dDW m <br />Paget - R�iArrxw®er <br />Policy Expiration DatMOM <br />Rek NNn.�ge,rer,I Clmcal.4Je <br />