SAXE-CLIFFORD, SUSAN 1 - 2003 - Laserfiche WebLink

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' ~=- WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY O INFORMATION PAGE a 1308-F412 ~ POLICY N0. 92-XP-7656-0 COVERAGE IS PROVIDED BY REPLACES N0. 92-W5-9146-5 STATE FARM FIRE AND CASUALTY COMPANY 31303 AGOURA RD, WESTLAKE VILLAGE,CA 91363-0001 NAMED INSURED & MAILING ADDRESS SUSAN SAXE CLIFFORD PHD INC 16530 VENTURA BLVD STE 203 ENCINO CA 91436-4535 NCCI CARRIER CODE N0. 14842 FEIN 954072886 LOCATION: 16530 VENTURA BLVD STE 203 ENCINO CA INSURED IS A CORPORATION COPYRIGHT 1987 NATIONAL COUNCIL ON COMPENSATION INSURANCE ------------------------------------------------------------------------------ 2. THE POLICY PERIOD IS FROM 07/01/2004 TO 07/01/2005 12:01 A.M. STANDARD TIME AT THE INSURED'S MAILING ADDRESS. ------------------------------------------------------------------------------ 3A. WORKERS COMPENSATION INSURANCE: PART ONE OF THE POLICY APPLIES TO THE WORKERS COMPENSATION LAW OF THE STATES LISTED HERE: CA 8. EMPLOYERS LIABILITY INSURANCE: PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE: BODILY INJURY BY ACCIDENT $ 500,000 EACH ACCIDENT BODILY INJURY BY DISEASE S 500,000 EACH EMPLOYEE BODILY INJURY BY DISEASE $ 500,000 POLICY LIMIT C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO ALL STATES EXCEPT ME, MT, ND, OH, RI, WA, WV, WY AND STATES LISTED IN 3A. THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES: WCOOOOOOA WC040301A FE-4893 WC000404/0484 WC040360A WC040407 WC000420* *EFFECTIVE 07/01/04 ----------------------------------------------------------- ----- 4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, CLASSIFICATIONS, RATES AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. -------------------------------- ---------------------------------------- PREMIUM BASIS TO- RATE/$100 ESTIMATED CCDE NOS. AND TAL ESTIMATED AN- REMUNERA- ANNUAL CLASSIFICATIONS NUAL REMUNERATION TION PREMIUM ---------------------------------------- ----------------- --------- --------- 8810 55,309 1.31 725 CLERICAL OFFICE EMPLOYEES - NOC COMPANY SURCHARGE FOR INCREASED EMPLOYERS LIABILITY LIMITS AS TO ' ;titY Sheedy ,,.,~. _ _:i1y Attorn TERRORISM PREMIUM 9740 75 17 MINIMUM PREMIUM $ 250 CALIFORNIA TOTAL ESTIMATED ANNUAL~PREMIUM $~ 817 PREMIUM ADJUSTMENT PERIOD SHALL BE ANNUAL DEPOSIT PREMIUM $ 817 STATE ASSESSMENT $ 2.00 SEE SURCHARGE OVERFLOW PAGE PREPARED 04/22/2004 COUNTERSIGNED___ ____ ____ __- ______ _ -_ ___ WC 00 00 O1 04-84 •s 80 2083 3966 BY AGENT RTvI Copyright 2002 Naaonal C:alnal on C;ompensaoon insuranaa, inc.