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WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY O <br />e,/ INFORMATION PAGE <br />POLICY N0. 92-D3-2318-6 COVERAGE IS PROVIDED BY 23-1308-F412 <br />REPLACES N0. 92-EV-1341-9 STATE FARM FIRE AND CASUALTY COMPANY <br />900 OLD RIVER RD, BAKERSFIELD CA 93311-6000 <br />1. NAMED INSURED & MAILING ADDRESS NCCI CARRIER CODE N0. 14842 <br />SUSAN SAXE CLIFFORD PHD INC FEIN 954072886 <br />ENCINOVCATU9A4B6V4535E 203 j6530I~ENTURA BLVD STE 203 <br />ENCINO CA <br />INSURED IS A CORPORATION <br />COPYRIGHT 1987 NATIONAL COUNCIL ON COMPENSATION INSURANCE <br />----------------------------------------------- <br />2. THE POLICY PERIOD IS FROM 07/01/2006 TO 07/01/2007 12:01 A.M. STANDARD TIME <br />AT THE INSURED'S MAILING ADDRESS. <br />------------------------------ _____ <br />------------------------ <br />3A. WORKERS COMPENSATION INSURANCE: PART ONE OF THE POLICY APPLIES TO THE <br />WORKERS COMPENSATION LAW OF THE STATES LISTED HERE: CA <br />B. EMPLOYERS LIABILITY INSURANCE: PART TWO OF THE POLICY APPLIES TO <br />WORK IN EACH STATE LISTED IN ITEM 3A THE LIMITS OF OUR LIABILITY <br />UNDER PART TWO ARE: BODILY INJURY BY~ACCIDENT $ 500,000 EACH ACCIDENT <br />BODILY INJURY BY DISEASE $ 500,000 EACH EMPLOYEE <br />C. OTHER STATES INSURANC~~IPARTNTHREEBOFDTHEAPOLICY APPLES TOLALL STATES <br />EXCEPT ME, MT, ND, OH, RI, WA, WV, WY AND STATES LISTED IN 3A. <br />D. THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES: WCOOOOOOA <br />WC040301A FE-4893 WC000404/0484 WC040360A WC040407 WC040601A <br />WC000422* WC000113* <br />*EFFECTIVE 07/01/06 <br />-------------------------------------------------------------------- <br />4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF <br />RULES, CLASSIFICATIONS, RATES AND RATING PLANS. ALL INFORMATION <br />REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. <br />---------------------------------------------------------- <br />CODE NOS. AND PREMIUM BASIS TO- RATE/$100 ESTIMATED <br />CLASSIFICATIONS TAL ESTIMATED AN- REMUNERA- ANNUAL <br />________________________ NUAL REMUNERATION TION PREMIUM <br />8810 39,229 _--1,33_- ------522 <br />CLERICAL OFFICE EMPLOYEES - NOC <br />COMPANY SURCHARGE FOR INCREASED <br />EMPLOYERS LIABILITY LIMITS <br />FOREIGN TERRORISM PREMIUM 9740 <br />0 <br />N <br />O <br />39,229 <br /> <br />03 <br />75 <br />12 <br />MINIMUM PREMIUM $ 250 CALIFORNIA TOTAL ESTIMATED ANNUALIPREMIUM $I 609 <br />---------------------- ____ <br />------------------------------------------------- <br />PREMIUM ADJUSTMENT PERIOD SHALL BE ANNUAL DEPOSIT PREMIUM $ 609 <br />STATE FRAUD SURCHAR $ V~ 1.00 <br />PREPARED 04/24/2006 SEE SURCHARGE 0 ERFLOW PAGE J V <br />COUNTERSIGNED <br />WC 00 00 01 04-84 'f'z 80 2151 6738 BY AGENT <br />m <br /> <br />