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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. 1 K 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 />ITEM 3 C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: <br />All states except North Dakota, Ohio, Washington, Wyoming and states designated in Item 3.A. on <br />the Information Page. <br />Countersigned by: <br />Issue Date <br />To report a claim, call your Agent or 1-844-325-2467 <br />WC 99 06 83 <br />59985843 POLSVCS 280 INSURED COPY 001231 PAGE 25 OF 30 <br />