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~- - ~ WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY <br />INFORMATION PAGE <br />1308-F412 ~t <br />POLICY NO. 92-XP-7656-0 COVERAGE IS PROVIDED BY ' <br />REPLACES N0. 92-W5-9146-5 31303SAGOURAARD,FUIESTLAKECVILLAGE,C~M91363-0001 <br />NAMED INSURED & MAILING ADDRESS <br />SUSAN SAXE CLIFFORD PHD INC <br />16530 VENTURA BLVD STE 203 <br />ENCINO CA 91436-4535 <br />NCCI CARRIER CODE NQ. 14842 <br />FEIN 954072886 <br />16530I~ENTURA BLVD STE 203 <br />ENCINO CA <br />INSURED IS A CORPORATION <br />COPYRIGHT 1987 NATIONAL COUNCIL ON COMPENSATION INSURANCE <br />2. THE POLICY PERIOD IS FROM 07/01/2004 TO 07/01/2005 12:01 A.M. STANDARD TIME <br />AT THE INSURED'S MAILING ADDRESS. <br />----------- - ----------------------------------------------------------------- <br />3A. WORKERS COMPENSATION INSURANCE: PART ONE OF THE POLICY APPLIES TO THE <br />WORKERS COMPENSATION LAW OF THE STATES LISTED HERE: CA <br />B. EMPLOYERS LIABILITY INSURANCE: PART TWO OF THE POLICY APPLIES 70 <br />WORK IN EACH STATE LISTED IN ITEM 3A, THE LIMITS OF OUR LIABILITY <br />UNDER PART TWO ARE: BODILY INJURY BY ACCIDENT $ 500,000 EACH ACCIDENT <br />BODILY INJURY BY DISEASE S 500,000 EACH EMPLOYEE <br />BODILY INJURY BY DISEASE $ 500,000 POLICY LIMIT <br />C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO ALL STATES <br />EXCEPT ME, MT, ND, OH, RI, WA, WV, WY AND STATES LISTED IN 3A. <br />D. THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES: WCOOOOOOA <br />WC040301A FE-4893 WC000404/0484 WC040360A WC040407 WC000420* <br />*EFFECTIVE 07/01/04 <br />------------------------------------------------------------------------------ <br />4, THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF <br />RULES. CLASSIFICATIONS. RATES AND RATING PLANS. ALL INFORMATION <br />REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. <br />------------------------------------------------------------------------------ <br />PREMIUM BASIS TO- RATE/$100 ESTIMATED <br />CCDE NOS. AND TAL ESTIMATED AN- REMUNERA- ANNUAL <br />CLASSIFICATIONS NUAL REMUNERATION 7ION PREMIUM <br />---------------------------------------- ----------------- --------- --------- <br />8810 55,309 1.31 725 <br />CLERICAL OFFICE EMPLOYEES - NOC <br />COMPANY SURCHARGE FOR INCREASED <br />EMPLOYERS LIABILITY LIMITS <br />75 <br />AS TO <br />_;iry <br />ERRORISM PREMIUM 9740 <br />17 <br />9INIMUM PREMIUM 8 250 CALIFORNIA TOTAL ESTIMATED ANNUAL PREMIUM $ 817 <br />'REMIUM ADJUSTMENT PERIOD SHALL BE ANNUAL DEPOSIT PREMIUM S 817 <br />SEE SURCHARGE OVERFLOWSPAGEENT $ 2.00 <br />'REPARED 04/22/2004 COUNTERSIGNED <br />IC 00 00 01 04-84 i-s 80 2083 3966 BY AGENT <br />Capyripht 20(12 Nattgnal C:oUnal on c:ompensatwn Insurance, ma <br />