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Tl. United Way Agency <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />INFORMATION PAGE REVISION NO. <br />❑ This is a 3 Year Fixed Rate Polity <br />..LTIONAL INSURANCE COMPANY <br />pony Cod. No. 2M12 ❑ New [] Revision Policy No. 990DOM160021 <br />R RCne al: ❑ Reissue: ❑ Rewritc of Prior Policy No 390000316=1 <br />Pine 1 <br />TOXIC Date 12.1042 Aact. No. 107197 <br />Pol. Tenn 1 Year <br />Pay Term I Yr. St. CA <br />Co. <br />Town <br />I Sh <br />1 96 Adj. <br />Adjustment Data: <br />AUDITED <br />THIS INFORMATION PACE, WITH POLICY PROVISIONS AND ENDORSEMENTS, IF ANY. <br />Anniv. Rate Data <br />COMPLETES TH IS POLICY. <br />.-- NADIF.D INSURED AND MAILTNO ADDRESS <br />PRODUCER 32 BRANCH CODE 010 <br />I )UTHWEbr MINORITY ECONOMIC <br />AARIS, LLC <br />sELOPMENT ASSOCIATION (VITA) <br />37 GROVE STREET <br />-+,. VVEST 2ND STREET <br />SAN FRANCISCO CA 94102 <br />S WTA ANA CA 92T63 <br />IIISYTed is' ❑ IndiYidual ❑ Partnership ❑ <br />Corporation, or ( Other. NON-PROFTr <br />O ther workplaces not shown above: <br />See Location Schedule <br />.'_ Identification number(s): <br />Soo Schedule <br />2. The policy period is from 10-27-2002 to 10-27-2003 at 12:01 A.M. Standard Time at the insurad's mailing address. <br />1J1:11 V!LL rlLll.tllllllCn.. <br />A. Workers Compcnvtioa Insurance: Part Out of the policy applies to the Workers Compensation Law of the states lilted here: <br />CA <br />Employers Liability Insurance: Part Two of the policyapplies to the work in each state listed in item 3.A. <br />The Limits of our Liability under Part Two are: Bodily Injury by Accident 1,000,000 each Accident <br />Bodily Injury by 1)iseasc 1.0m,000 policy limit <br />Budilylgjury by Discasa 1,000,000 each employee <br />Other States tnsurnnce: All staics except North Dakota. Ohio, W; Iiingtuh, West Virginia, Wyoming and states designated in Item 3A of the <br />Information Page. <br />D. This policy includes these endorstmenta and schedules: <br />Sec Schedule of Forms and Endomcments _ -- <br />u. The premium for this puhcy will be determined by our Manual of Rules. Classifications, Rates and Rating Plans. All information required on folli <br />(:L!>sificalim, Schedule is subjeCI to verification and chart c by audit. Scu Extension Schedule Attached. <br />4,607 TOTAL ESTIMATED ANNUAL POLICY PREMIUM If indicated, interim adjustments of <br />ADJUSTMENT PREMIUM UlIE (Addl., a Rcrurn Premium- A minus premium shall be made: <br />figure means Return Premium) ❑ Semi -Annually <br />S 1,381 MINIMUM PREMIUM ❑ Quartcrl-v <br />S DEPOSIT PREMIUM ❑Monthiv <br />.. Scivicing Officr. <br />I <br />