Laserfiche WebLink
Coverage Is Provided In: Policy Number: <br />Liberty Ohio Security Insurance Company - a stock company IXWS (25) 59 98 58 431 <br />Mutual Policy Period: <br />INSURANCE From 06/23/2024 To 06/23/2025 <br />Endorsement Period: <br />NCCI Co. No. 19291 I From 03/24/2025 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 <br />POLICY FORMS AND ENDORSEMENTS <br />This section lists all the Forms and Endorsements that make up your policy. Refer to these documents as needed for <br />detailed information concerning your coverage. <br />FORM NUMBER TITLE STATE(S) Applicable <br />WC 00 00 00 C Workers Compensation and Employers Liability Insurance Policy CA <br />WC 00 04 21 F Catastrophe (Other Than Certified Acts of Terrorism) Premium Endorsement CA <br />WC 00 04 22 C Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement CA <br />" WC 04 03 01 D Policy Amendatory Endorsement - California CA <br />WC 04 03 10 Duty To Defend Endorsement - California CA <br />WC 04 03 18 C Limited Liability Company Coverage/Exclusion Endorsement - California CA <br />Endorsement Agreement Limiting and Restricting This Insurance <br />WC 04 03 60 B Employers' Liability Coverage Amendatory Endorsement - California CA <br />WC 04 04 21 Optional Premium Increase Endorsement - California CA <br />WC 04 06 01 B California Cancelation Endorsement CA <br />Countersigned by: <br />Issue Date <br />To report a claim, call your Agent or 1-844-325-2467 <br />WC 99 06 85 <br />59985843 POLSVCS 280 INSURED COPY 001231 PAGE 29 OF 30 <br />