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e3/16/20e5 09:53 7146475779 SANTA ANA FIRE DEPT PAGE 02/04 <br />03/15/2005 12:57 7602430996 NI DESEP.T COMMUNICAT PAGE 02 <br />I <br />_ Im Tm T - n IM If MOT A MILL AND No NOM Y UNSfR T,TATZINNT ,g RNOLONK. <br />STr,09E�:Lw <br />oFnci 9API PMAI�CIieo POLICY DtCLJ1RAT10Ns <br />C:OM/ <br />) N s uWMMA WONOMr COhOVAISATION AND ENIPLOYHPS LIABILITY POLICY <br />FUDECLARATKOM AM A PART OF THE WOKERS' CO��TP6MSATNIN POLICY RNON:ATW 1RWE'OM <br />THIS INSURANCE is ■rrXCTIvE rRw <br />12:01 A.M., PACIFIC STANDARD TIME <br />6-30-04 TO 6-22-05 AND SMALL <br />iA11TONATICALLY REMEN SACS 6-22 <br />URTIL CANCELLED <br />RI DESERT COMMUNICATIONS <br />17161 JASMINE ST <br />VICTORVtLLE, CALIF 92392 <br />NAME OF EMPLOYER -- <br />TRADE NAMES - <br />CONTINUOUS POLNCYI770946-04 <br />DRPOSIT PRE7IIUM S1,456,00 <br />MINIUM PRRylI011 S205,06 <br />PREMIUM ADJUSTNSRT PERIOD MONTRL! <br />M SJ <br />CAZCOM INC <br />(A CORPORATION) <br />HI DESERT COMMUNICATIONS <br />LOCATIONS- 001 17181 JASMINE ST <br />VICTORVILLE CA 92392 <br />1, WORKERS' COMPENSATION INSURANCE - PART ONE OF THIS POLICY APPLIES TO THE <br />WORKERS' COMPENSATION LAWS OF THE STATE OF CALIFORNIA. <br />2- EMPLOYER'S LIABILITY INSURANCE - PART TWO OF TH15 POLICY APPLIES TO <br />LIABILITY UNDER THE LAWS OF THE STATE OF CALIFORNIA. THE LIMIT OP OM <br />LIABILITY INCLUDING DEPBNSE COSTS UNOER PART T40 IS, <br />S1,000,000 <br />CODE N0. PRINCIPAL WORK AND RATES EFPECTIVE PROM D6-30-04 TO 06-22-05 <br />INTERIM <br />BAse BILLING <br />RATE RATE* <br />9516 TELEVISION, VIDEO, AUPIO AND RADIO 11,42 9.71 <br />EQUIPMENT INSTALLATION, SERVICE OR <br />REFAIII--SHOP AND OUTSIDE. <br />8742 SALESPERSONS--OUTSIDK. 2.57 2.19 <br />6610 CLERICAL OFFICE EMPLOYEES--N.O.C. 2.24 1.91 <br />********BUREAU NOTE INFORMATION******** <br />CLIFFORD ZWARKOWSKI PREsIDanpt @(OVV£!) AS TO FORM <br />TOT71,L ESTINATSD A2nFUAL PREII111K $34,'-562 <br />COUNTERSIGH90 AND ISSUED AT SAIL FRANCISCO JULY 19, 2004 POLICY FORM L 1 <br />s 17 rwiN in^, mv.3-on (OVER PLEASE) <br />