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Senj By: Teen Challenge; 951682357; May-24-0F 9:17AM; Page 5/5 <br />2757 STFITE , P INS 7UND — yL UlbdL' ',---j4 Nl i Ul_n_w <br />STATE HQME OFFICE SAN'FRANCISCo ANNUAL RATING ENDORSEMENT <br />I N 8 LII I A HI C u IT I$ AGREED CHAT THE CLASSIFICATIONS AND RATES PER 5100 OF REMUNERATION APPEARING <br />INSURANCi <br />Tau N IN THE CONTINUOUS POLICY ISSUED TO THIS EMPLOYER ARE AMEfmEO AS SHOWN BELOW. <br />CONTINUOUS POLICY488-0000626-04 <br />IF YCU HAVE ANY OUESTIONS, PLEASE CONTACT YOUR IOCAI STATE FOND OFt ICF BELOW <br />SANTA ANA <br />17S0 Ed�:;T FOURTH STREET <br />SANTA ANA CA 9270S <br />(71,1) 565—S995 <br />Nothing harein ctnteined shall be hold to vary, titer, waive or extend my of the terms. Condltions <br />agreements or limitations of the Policy other than as herein stated. <br />When countareipned by a duly authorised officer or repreaemative of tho State Ccmparsalicn Instirvrce <br />Furs{, these dacfaraWns shall be rand and form part of the Policy. <br />ALyHpAIYEb NkPHESENTATIVE <br />PgESIp <br />MR0V ED 'AS 'lli tv: ... <br />As>isLan[ lv� -so ;, <br />COUNTERSIGNED AND ISSUED AT SAN FRANCISCO FEBRUARY 11, 2005 POLICY L PAGE .] OF It <br />