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WORKERS COMPENSATION AND EMPLUYERS~III;A6ILITY POLICY <br />INFORMATION PAGE ~ ~ - - <br />~CY N0. 92-EV-1341-9 COVERAGE IS PRO 'DEED 8Y 23 1308 F412 <br />REPLACES N0. 92-XP-7656-0 STATE FARM FIR AND CASUALTY COMPANY <br />900 OLD RIVER RD, B E~25FIELD CA 93311-6000 <br />t. NAMED INSURED & MCCA FNNNNFG ADDRESS FNCZCI CAI IER CODE N0. 14fi42 <br />16530 VEANiUR~~B`~DDSTED203C LOCATIO 7 886 <br />ENC[NO CA 91436-4535 , 16530 V T~JRA BLVD STE 2C13 <br />Q_aoD3- ~.'~7 ENCINO <br />~- aoo3-~`f7'v/ INSURED ~' Sil A CORPORA7IOPI <br />COPYRIGHT 1987 NATIONAL COUNCIL ON COMPENSATION I U~2ANCE <br />2. 7'HE POLICY PERIOD IS FROM 07/0 /2005 TO 07/01 .006 12 01 A.M STANDARD T1Mf: <br />AT THE INSURED'S MAILING ADDRE~S. i <br />-- --------CE------ -~-T- ------- <br />3A• EEWORKERS COMPENSATION LAW OFN1'HE STAiE~NLi~ EDP E~OLICCAqAAPPLIES TO THE <br />B. fu0RK0trEVRES,gCHIA$BTA7EYLIIigNgTED INEITEMRg3ArWOCCTIHIE NNLi T~LOFYOURPEIABIL~TYD <br />UNDER PART TWO ARE: 60DILY INJURY BY DISEA~ET j500,000 EACH EMPIQYEE <br />BODILY INJURRY II Y nnnnnn111111 <br />C. OTHER STATES INSURANBODIPARTNTHREE OFOTHEAPOL [Y~APPL~~S OLALL ~~ATES <br />EXCEPT ME, MT, ND, OH, RgSIEE, WA, WV, W1' AND STA':S~UL`IESTED IN 3A. <br />D~ wC04030igCYFEN48gDESw0000404N0~84EMWN040360AS ~~4040g W0000420* <br />WC04060tgM <br />i j *EFFECTIVE 07/01/0`_ <br />E ppE EE I,[ ~ ---•__-°---------------- <br />4. RULESRECiAMSI~JCATIppSNSOLRRIATESIANDBRATINGRPLANS: QLOURNMORMATSOOF <br />REOUIf~ED BELOW IS SUBJECT TO VERIFICATION AND A GE BY AUDIT. <br />---------- <br />000E NOS. AND PREMIUM SiS TO- REAETE/$100 ENSNTIMATED <br />CLASSIFICATIONS NUALEREM 1ERATION 7IONNERA PREMIUM <br />8810 ------ ----^---- --------- <br />ccCppLryryE~~RICAL OFFICE EMPLOYEES - NoC 3 2~9 1.46 573 <br />EMPLONERSULIABI~(TYORIMIT$EASED ~ 'i 75 <br />~l_~~ I~~ <br />/ ~~1~, ' { <br />~' <br />TERRORISM PREMIUM 9740 <br />3 <br />MINIMUM PREMIUM S 250 CALIFORNIA TOTAL ESTiMAT <br />!PREMIUM aOJUSTMEN7 PERIOD SH4LL BE ANNUAL <br />i PREPARED 04/22/2005 <br />WC '00 -00~.-01 04-84 <br />COUNTERSIGN <br />'F'x 80 2117 2826 BY AGENT_ <br />JUN 2 8 X76. <br />3~.qo i <br />29 I .03 12 <br />ANNUAL PREMIUM S 660 <br />EPOCSIT,5~1RPREMIUM S 66U <br />Ai~EAASSESHS~i~n~~r s 13:°00 <br />Z ~d DDSB 88L 8l8 'O 'Hd 'dL10.~~I <br />dH1i. . <br />W02fU WdLO' c. t 90Z-£Z-S <br />