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I al1L;Ilf <br />Workers' Compensation and Employers Liability <br />Insurance Policy <br />EMPLOYERS PREFERRED INS. CO. <br />policy Perio, tltl <br />POIIC�J.[�UtXlbt3r ,; From � •To' <br />A Stock Company <br />EIG 1571658 10 <br />12/01/2022 12/01/2023 <br />Iniued'eli's�etedWedrTimeattheaddress ofthe <br />'i to '. P... t, > y.i� <br />Trans d`` . ,_.77 <br />AMENDED DECLARATIONS <br />Effective: 12/01/2022 <br />NCCI Carrier# 31283 WCIRB CARRIER# 00920 <br />PRIOR POLICY NUMBER EIG157166809 <br />Napi�d nONO- and*0110ss> <br />°. sIi< ° �, ,, • ;�• <br />" � 4t� <br />a ., .. -' ""A9 " <br />NATIONAL POLYTECHNIC COLLEGE <br />UNITED AGENCIES (BURBANK) 1377002 <br />DBA MONTEBELLO CAREER <br />301 E COLORADO BLVD #200 <br />4105 SOUTH STREET <br />PASADENA, CA 91101 <br />LAKEWOOD CA 90712 <br />Telephone: 8182952263 <br />Customer # <br />Carrier # <br />FEIN # <br />Risk ID # <br />Entity of Insured <br />1 <br />31283 <br />954696502 <br />4565527 <br />CORPORATION <br />Additional Locations: <br />2. The Policy Period is from 12/01/2022 to 12/01/2023 12:01 a.m. Standard Time at the Insured's mailing address. <br />3. A. Workers Compensation Insurance: Part ONE of the policy applies to the Workers Compensation Law of the states <br />listed here: CA <br />B. Employers Liability Insurance: Part TWO of the policy applies to work in each state listed in Item 3A. <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 $ 1000000 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 ND, OH, WA, WY and states listed in item 3.A. <br />D. This policy includes these endorsements and schedules: See attached schedule. <br />4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans. <br />All information required below is subject to verification and change by audit. <br />SEE EXTENSION OF INFORMATION PAGE <br />Minimum Premium $ 750 <br />Assessments and Taxes $ <br />❑ This is a Three Year Fixed Rate Policy <br />Premium Adjustment Period: 0 Annual; <br />Countersigned this Day of <br />Issued Date: 10/27/2022 <br />Issuing Office EMPLOYERS PREFERRED INS. CO. <br />P.O. BOX 539003 <br />HENDERSON, NV 89053-9003 <br />Issued Date 10/27/2022 <br />WC990630 (5198 Ed.) <br />Expense Constant $ 160 <br />Premium Discount $ -87 <br />Total Estimated AnnualPremlum $ 6,784 <br />❑ Semiannual; ❑ Quarterly;; ❑ Monthly <br />INSURED COPY <br />Page 1 of <br />Authorized Representative <br />