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<br />i J&n'05 04 02:58p <br /> <br />DisOOV~~~ Mus~um <br /> <br />714 540-1832 <br /> <br />p.1 <br /> <br />STATE ""M~ Df"OE SAN FRANCISOO.¡ ANNUAL RATING ENDORSEMENT <br />COMPIiNSATION IT IS AGREED THAT THE CLASSIFICATIONS AND RATES pm $100 OF REMUNERATION APPEARING <br />INSURANCE <br />FUND IN THE CONTINUOUS POLICY ISSUED TO 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 NOT NEEDED FOR NEXT YEAR, PLEASE TELL us. <br /> <br />IMPORT ANT" THIS IS NOT A BILL CONTINUOUS POLICY 15!14455-03 <br /> <br />SEND NO MOIIEY UNLESS STATEMENT IS ENCLOSED <br />THE RAl' PERIOD BEGINS AND ~NDS AT 12o0'AM <br />PACIFIC Sl'ANDARD TIME <br /> <br />RATING PERIOD <br /> <br />6-30-03 TO <br /> <br />6-30-04 <br /> <br />CENTENNIAL HERITAGE MUSEUM <br />INC. <br />3101 W HARVARD ST <br />SANTA ANA, CALIF 92704 <br /> <br />DEPOSIT PREMIUM <br />MINIMUM PREMIUM <br />PREMIUM ADJUSTMENT pERIOD <br /> <br />$1,419.00 <br />$200.00 <br />QUARTERLY <br />R SP <br /> <br />NAME OF EMPLOYER- <br /> <br />CENTENNIAL HERITAGE MUSEUM INC. <br />(A NON-PROFIT CORP.) <br /> <br />COPE NO. <br /> <br />PRINCIPAL WORK AND RATES EFFECTIVE FROM 06-30-03 TO 06-30-04 <br /> <br /> <br />8017 <br />8838 <br /> <br />STORES--RETAIL--N. O.c. <br /> <br /> JNl¡,;¡UI1 <br />BASE BILLING <br />RATE RATE:" <br />12.52 11.18 <br />5.25 4.69 <br /> <br />MUSEUMS--ALL EMPLOYEES <br /> <br />**"""""'*BUREAU NOTE INFORM.ATION*"""*"** <br /> <br />FEIN 953665050 <br /> <br /> <br />-7 y/y <br /> <br />;.. <br /> <br />COUNTERSIGNED AND ISSUED AT SAN FRANCISCO <br /> <br />,~,,~~ ~... ", <br /> <br />JULY 22, 2003 <br /> <br />POLICY FORM L <br /> <br />1 <br />