|
<br />Ja~ 05 04 02:58p
<br />
<br />Disoove~~ Museum
<br />
<br />714 540-1932
<br />
<br />p.1
<br />
<br />STATE HOM~ OFFICE SAN FRANCISCO I ANNUAL RATING ENDORSEMENT
<br />COMPENSATION IT IS AGREED THAT THE CLASSIFICATIONS AND RATES PER $100 OF REMUN~RATION APPEARING
<br />INSURANCE
<br />FUND IN THE CONTINUOUS POLICY ISSUED ro THIS EMPLOYER ARE AMENDED AS SHOWN BELOW
<br />
<br />HERE ARE YOUR NEW RATES FOR THE PERIOD INDICATED. IF YOUR NAME OR ADDRESS SHOULD
<br />BE CORRECTED OR IF INSURANCE IS NDT NEEDED FOR NEXr YEAR, PLEASE TELL US.
<br />
<br />IMPORTANT THIS IS NOT A BILL CONrlNUOUS POLICY 1594455-03
<br />
<br />SEND NO MONEY UNLESS STATEMENT IS ENCLOSED
<br />THE ~TING PERIOD BEIiINS AND END~ AT 12,ðUN
<br />PACIfIC STANDARD TIME
<br />
<br />RATING PERIOD
<br />
<br />6-30-03 TO
<br />
<br />6-30-04
<br />
<br />* INTERIM BILLING RATES WILL BE USED ON PAYROLL REPORTS. THEY TAKE INTO ACCOUNT
<br />RATING PLAN CREDITS (OR DEBITS) WHICH WILL APPLY AT FINAL BILLING AND AN
<br />~STIMATE Or- YOUR PRfJUUI1 DlSCOUNT AS DETAILED BELOW.
<br />
<br />RATING PLAN CREDITS (DEBITS) EFFECTIVE FROII 06-30-03 TO 06-30-.Qi!
<br />
<br />RATING PLAN IIODIFIER
<br />
<br />1.00000
<br />
<br />
<br />ESTII1AT~D PREMIU/I DlSCOUNT MODIfIER
<br />
<br />0.89319
<br />
<br />COMPOSITE FACTOR APPLIED TO BASE RATES TO DERIVE
<br />INTERI/I BILLlN(j RATES
<br />
<br />0.89319
<br />
<br />*,'** ** ** H,,* *,,*** ****** * ** *,,* **',* Mo',' H** "*'°' *,,*,,**,,** * ',H**,',' H', ,'", *" ,',H'", *,' *""""
<br />i,
<br />
<br />
<br />* PREMIUM DISCOUNT SCHEDULE EFFECTIVE FROII 06-30-03
<br />" ESTlMATED MODIFIED PRE/HUM IS DISCOUNTED ACCORDING TO THE
<br />" FIRST ABOVE
<br />$2,500 $2,500
<br />0.0% 17.5%
<br />
<br />TO 06-30-04
<br />FOLLOWING SCHEDULE: "
<br />
<br />,~
<br />
<br />"
<br />"
<br />*
<br />
<br />",. ,**H.*"**"**"~WW"**"**.* ,,*,>;,,>.********. ."Hi,H.""**"""""'.*".""". "*H,'",***,,,,***
<br />
<br />THE ESTIMATED PREMIUI! DISCOUNT TS BASED ON AN ESTIMATE OF YOUR PAYROlL ACTUAL
<br />P¡Œ/liUM DISCOUNT APPLIED AT FINAL BILLING WILL BE BASED ON THE ACTUAL PAYROLL
<br />REPORTED ON YOUR POLICY AND SUBJECT TO AUDIT.
<br />
<br />'yt} ¡ , ~
<br />A/I lkJC'j .5?¡,y
<br />
<br />COUNTERSIGNED AND ISSUED AT SAN FRANCISCO
<br />
<br />JULY 22, 2003
<br />
<br />POLICY FORM L
<br />
<br />2L
<br />
<br /><"'" <no.. '0«' 'nc", ^ ""'
<br />
<br />'~""n n, .. ~"'
<br />
|