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r <br />No MnNFv IINI F95 tiTATEMENT IS ENCLOSED. <br />HOME OFFICE SAN FRANCISCO POLICY DECLARATIONS <br />CALIFORNIA WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY POLICY <br />THESE DECLARATIONS ARE A PART OF THE WORKERS' COMPENSATION POLICY INDICATE[) HEREON. <br />THIS INSURANCE IS EFFECTIVE lriWX <br />12:01 A.M., PACIFIC STANDARD TIME CONTINUOUS POLICY9304403-21 <br />8-26-21 TO 8-26-22 AND SHALL <br />AUTOMATICALLY RENEW EACH 8-26 <br />UNTIL CANCELLED <br />ELITE SPECIAL EVENTS, INC DEPOSIT PREMIUM $0.00 <br />11278 LOS ALAMITOS BLVD <br />LOS ALAMITOS, CALIF 90720 MINIMUM PREMIUM $1,400.00 <br />PREMIUM ADJUSTMENT PERIOD QUARTERLY <br />N SP <br />NAME OF EMPLOYER— ELITE SPECIAL EVENTS, INC (A CORP) <br />TRADE NAMES— ELITE SPECIAL EVENTS, INC <br />LOCATIONS— 11278 LOS ALAMITOS B <br />CYPRESS CA 90720 3958 <br />1. WOREERS' COMPENSATION INSURANCE — PART ONE OF THIS POLICY APPLIES TO THE <br />WORKERS' COMPENSATION LAWS OF THE STATE OF CALIFORNIA_ <br />2. EMPLOYER'S LIABILITY INSURANCE — PART TWO OF THIS POLICY APPLIES TO <br />LIABILITY UNDER THE LAWS OF THE STATE OF CALIFORNIA. THE LIMIT OF OUR <br />LIABILITY INCLUDING DEFENSE COSTS UNDER PART TWO IS, <br />$1,000,000 <br />CODE NO. PRINCIPAL WORK AND RATES EFFECTIVE FROM 08-26-21 TO 08-26-22 <br />INTERIM <br />PREMIUM BASE BILLING <br />BASIS RATE RATE* <br />9095-1 EVENT MARKET, FESTIVAL OR TRADE SHOW 30000 9.24 9.99 <br />OPERATION --ALL EMPLOYEES--N.O.C. <br />********BUREAU NOTE INFORMATION******** <br />TED HOLCOMB P 50 B <br />TOM MOORE CEO,S 50 8 <br />TOM MOORE T 0 8 <br />FEIN 260747948 <br />TOTAL ESTIMATED ANNUAL PREMIUM $2,997 <br />COUNTERSIGNED AND ISSUED AT SAN FRANCISCO AUGUST 30, 2021 PO. <br />SCIF FORM 10961A IREV.7-20141 (OVER PLEASE) <br />09 <br />x weleir4nllg""mtotwi°n z <br />Risk Management SPeci&lst <br />