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~ coav <br />MARKEL INSURANCE COMPANY <br />A STOCK COMPANY <br />TEN PARKWAY NORTH <br />DEERFIELD, IL 60015 <br />~w~,~a.. ~ 800-431-1270 <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />INFORMATION PAGE <br />NCCI No. 22616 <br />New No. <br />State Unemployment LD. No. or Identifying Number as Required: <br />1. Insured: Santa Ana Police Officers Association <br />(a nonprofit organization) dba <br />Mailing 1607 N SYCAMORE ST <br />Policy No. MWC0017162-01 <br />Renewal of Policy Number New <br />Address SANTA ANA, CA 92701-2352 <br />Individual ~ Partnership ~ Corporation <br />FEIN: 952748200 <br />Producer: Invensure Insurance Brokers, Inc <br />Mailing 17912 Mitchell S. <br />Address Irvine, CA 92614 <br />or ~ Nonprofit <br />Other workplace not shown above: See Attached Location Schedule <br />2. Policy Period: The policy is from 12/01/2011 to 12/01/2012 [12.01 AM Standard Time) at the insured's mailing address. <br />3. A. Workers Compensation Insurance: Part One of this policy applies to the Workers Compensation Law of the states listed here: <br />CALIFORNIA <br />B. Employers liability Insurance: Part Two of this policy applies to work in each state listed in Item 3A .The limits ofd ~ <br />liability under Part Two are: ~~'~" r, <br />Bodily Injury by Accident: $ 1,000,000 each accident ~~d~E ~ '' #`~~-, fs -~- <br />Bodil In' b Disease: $ 1 000 000 ~ ~~ ~~ <br />Y Jam' Y policy limit <br />Bodily Injury by Disease: $ 1,000,000 each employee ~ ' 3oyepb St~A o~D~y <br />C. Other States Insurance: Part Three of this policy applies to the states, if any, listed here: - ~ Ag9t9tapt C~t`J <br />,/ . <br />NO COVERAGE AFFORDED FOR OTHER STATES. <br />D. This Policy includes these endorsements and schedules: MDWC1000, WC040002, WC040003, WC040004, WC040005, <br />MWC12000510, WCOOOOOOB, W0000419, W0000422A, WC040301A, WC040360A, WC040601A, MWC14030510, <br />MWC14040510, PN049901D, PN049902B, PN049904, MPWC10000510, MJWC1000, MPIL 1007 <br />4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and <br />Rating Plans. All information required below is subject to verification and change by audit. <br />Code Premium Basis Total Rate Per <br />Classification No Estimated Annual $100 of Estimated Annual Premium <br />Remuneration Remuneration <br />See WC 04 00 OS Extension of Information Page <br />MINIMUM PREMIUM $165.00 TOTAL ESTIMATED ANNiJAL PREMIUM $2,321.00 <br />TAXES & ASSESSMENTS $128.00 <br />IF INDICATED BELOW, INTERIM ADJUSTMENTS OF PREMUIM SHALL BE MADE: <br />Semi-Annually X Quarterly Monthly $1,158.00 Deposit Premium $Per Installment Endr <br />Issuing Office: Omaha, Nebraska <br />Countersigned by: <br />DWC 1000 (OS/10) <br />II IIIZI II ll iI~III III,IIII I,II III II IIII 1 of28 1111 II Il IIII III II III 111 l IIIIIIIIIi I ll <br />Mwcooi ~~ ez-oi <br />