MATCH POINT TENNIS ACADEMY LLC. (3)

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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 89 06 00 B (Ed. 7-01) POLICY INFORMATION PAGE ENDORSEMENT The following item(s) ❑ Insured's Name(WC 89 06 01) ❑ Item 3.13. Limits(WC 89 06 12) ❑ Policy Number(WC 89 06 02) ❑ Item 3.C. States(WC 89 06 13) ❑ Effective Date(WC 89 06 03) ❑ Item 3.D. Endorsement Numbers(WC 89 06 14) ❑ Expiration Date(WC 89 06 04) ❑ Item 4.' Class, Rate, Other(WC 89 04 15) ❑ Insured's Mailing Address(WC 89 06 05) ❑ Interim Adjustment of Premium(WC 89 04 16) ❑ Experience Modification(WC 89 04 06) ❑ Carrier Servicing Office(WC 89 06 17) ❑ Producer's Name(WC 89 06 07) ❑ Interstate/Intrastate Risk ID Number(WC 89 06 18) ❑ Change in Workplace of Insured(WC 89 06 08) ❑ Carrier Number(WC 89 06 19) ❑ Insured's Legal Status(WC 89 06 10) ❑ Issuing Agency/Producer Office Address(WC 89 06 25) ❑ Item 3.A. States(WC 89 06 11) is changed to read: WAIVER OF SUBROGATION IS ADDED TO THE POLICY IN FAVOR OF :City of Santa AnaAttention: Parks, Recreation and Community Services20 Civic Center Plaza, M-23Santa Ana, CA 92702 See Extension of Information Page and any other document. * Item 4. Change To: Classifications Code Premium Basis Total Rate Per Estimated No. Estimated Annual $100 of Annual Remuneration Remuneration Premium See Extension of Information Page Total Estimated Annual Premium $7, 588.00 Total Surcharges and Assessments $459.00 Total Estimated Cost $8, 047.00 Minimum Premium: $859.00 CA Deposit Premium: All other terms and conditions of this policy remain unchanged. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 03/24/2025 Policy Effective 06/23/2024 State Policy No. XWS (25) 59 98 58 43 Insured MATCH POINT TENNIS ACADEMY LLC Insurance Company Ohio Security Insurance Company WC 89 06 00 B (Ed. 7-01) Endorsement No. 0001 Premium $0.00 19291 Countersigned by: © 2001 National Council on Compensation Insurance, Inc.