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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 22 A <br />(Ed. 9-08) <br />Schedule <br />I State ~ Rate ~ Premium <br />CA 0.04 $98.00 <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br />Endorsement Effective 12/01/2011 Policy No. MW00017162-01 <br />Insured Santa Ana Police Officers <br />Association (a nonp . <br />Insurance Company Markel Insurance Company Countersigned by <br />W0000422A <br />.. 9-08) <br />(U Copyright 2008 National Council on Compensation Insurance, Inc. All Rights Reserved. <br />Endorsement No. <br />Premium $(See Attached) <br />15 of 28 <br />