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Coverage Is Provided In: Policy Number: <br />Liberty Ohio Security Insurance Company - a stock company �XWS (25) 59 98 58 43 <br />Mutual Policy Period: <br />INSURANCE From 06/23/2024 To 06/23/2025 <br />Endorsement Period: <br />NCCI Co. No. 19291 I From03/24/2025 To 06/23/2025 <br />Workers Compensation and 12:01 am StandardTime <br />at Insured'sMailingAddress <br />Employers Liability Insurance Policy <br />Information Page <br />Named Insured Agent <br />MATCH POINT TENNIS ACADEMY LLC (949) 334-5330 <br />ACRISURE, LLC DBA MPX INSURANCE <br />SERVICES <br />EXTENSION OF INFORMATION PAGE State: CALIFORNIA <br />ITEM 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 />Classifications Code Premium Basis - Total Rate per Estimated <br />No. Estimated Annual $100 of Annual <br />Remuneration Remuneration Premium <br />MATCH POINT TENNIS ACADEMY LLC <br />800 Cabrillo Park Dr <br />Santa Ana, CA 92701-4648 <br />NLC 001 CSN 001 state 04 exp rec link 00001 <br />Clubs - Sports - Including Restaurant Employees Retail Store <br />Employees and Receptionists <br />9053 266,225.00 2.72 7,241.00 <br />Total Subject Premium <br />7,241.00 <br />Premium Modified to Reflect Experience Mod. Of <br />9898 <br />.000 <br />7,241.00 <br />Price Point Modification <br />9734 <br />debit <br />1.011 <br />80.00 <br />Total Estimated Annual Standard Premium <br />7,321.00 <br />WC Expense Constant <br />0900 <br />160.00 <br />Terrorism <br />9740 <br />266,225.00 <br />.03 <br />80.00 <br />Catastrophe (Other than Certified Acts of Terror.) <br />9741 <br />266,225.00 <br />.01 <br />27.00 <br />State Estimated Annual WC Premium <br />7,588.00 <br />WC Administration Revolving Fund Assessment <br />0935 <br />2.4604 <br />187.00 <br />Uninsured Employers Benefits Trust Fund Assessment <br />0937 <br />.1505 <br />11.00 <br />Subsequent Injuries Benefits Trust Fund Assessment <br />0938 <br />1.5891 <br />121.00 <br />Occupational Safety and Health Fund Assessment <br />0939 <br />.7266 <br />55.00 <br />Labor Enforcement and Compliance Fund Assessment <br />0992 <br />.7109 <br />54.00 <br />WC Fraud Account Assessment <br />9703 <br />.4122 <br />31.00 <br />CIGA Surcharge <br />0936 <br />.0000 <br />.00 <br />CA Total Cost <br />8,047.00 <br />Countersigned <br />by: <br />Issue Date <br />To report a claim, call your Agent or 1-844-325-2467 <br />WC 99 06 84 <br />59985843 POLSVCS 280 <br />INSURED COPY <br />001231 <br />PAGE 27 OF 30 <br />