|
<br />. ~F'8-0?-;:;-~~~~P :1.0: 4[1
<br />
<br />[t::~'~1B
<br />
<br />?:t..r.<,EIE't,2L'jL.;}
<br />
<br />F'. ~~2
<br />
<br />uti
<br />
<br />. . ,,: ..... ...... .;'0~c-;~r~?ri,~fH0:';F::~>.,I;'~'/"";"r~::
<br />'Republiclriderri:riitY~Comp~ofCafiforn1a'2':' '.
<br />Company N<>. 21561
<br />
<br />'WCWOOO1A
<br />
<br />. .
<br />1. N.m. aod",.m.g",,"- .;clbo ~
<br />:Dmm. A.~no<<, J"Jl:J;Ill"I 3;)-M:'11)9~4.
<br />;;;"J..7," Jm:J:N:B"QJ;j:B'l"
<br />~ AM- 'CA 9~705
<br />
<br />WORKERS' COMi'ENSAnoN ANDOOLOYERS'LlAllIIirY PGUCY
<br />INFO~TiONPAGr; .
<br />~ .
<br />""'IIlD.~nt,,' """Y
<br />
<br />I'ohoy......., 1$22':5.- O~ .
<br />~~"Q1! ,~Uo..Y-.l'ftbbm;'J:152:~05--OJ.-
<br />
<br />othet w()~ IlOt $oWn aboorr:: h1stIred is: ,cO~atioU
<br />
<br />2.Thc:POlioy",)CJiodra!rom .~ :10" 2001 To" ~rj..:l.10..' 20Q2 12;Ol'a&~.~atti.~lji~~.
<br />3:A. W_~_rm.n-.".PmtOne ",1bo__tolhr Won...' C""'_ion~.flbo"-)_""",
<br />CA
<br />a ~ny~~ ~~:Pu:t 'fwo.ofthcpolj(yAPPl\es toWOJ:kine.,;.h~_1:iJtt4in~ 3-A..,'l"he 1~~0Ul"~ ~Part"l'9,rQ ~~
<br />BO<blY!>1illlybyAoo;de", fl,.Mo,oao ___
<br />Bc4i.1VJ~ury~D~ 11.,000,,000 ~~
<br />BodiI":yhijutyby-~ ,J....OOO,G(l(J palil;:ytfinU
<br />
<br />c. ()th,;r &atelf .lnsrmuilX:~ Part,~ ilf91ie~ (Q d>> ittW$, ifMy', llsocr;l JKre;:
<br />l!IOO1.e
<br />
<br />D. This poli.cy I.toc:1udts ~se "'~l!; aDd: j;jchedul~.;
<br />1.WC;OJ, 2.NC040&07, 3.~608, 4.~40"OA, $.W~2D, 6.WC040601A
<br />
<br />4. 1'ht: prcmi:im,furl:l1i&pc:,I,icy w:il.l:be~ b:y ow:.M.unLIIi ofRulel>"Cf~Jtat.e-:.~~pbtu- AU ~n ~ btllMw is!lllltied'
<br />to ~Bnd.cba:olJ:- by:wdit. " .
<br />"'=MuD....
<br />('.<>de T__ lWoP",,$l00 _d_
<br />No. Cl;m;l&:abon .Am:lu!.l. ~~101\ ofF.~-~~ ~
<br />
<br />001. (1) ClElUCAL OFFICE EMPLOYImS-N.().C.
<br />0742(1) SAl.ESl'F.RS<)NS..QUTSIDF.
<br />
<br />.4,591.tOOQ
<br />*J.,.5(l1,000
<br />
<br />f1.:1.4
<br />".37
<br />
<br />.S2:,33'7
<br />'~U.411i#
<br />
<br />E><pm:Jo... _ 80%BN(20142'l<l)
<br />_....lit
<br />T()ta,( A(ljusled. Slate Ad" Pmmium
<br />
<br />21. S<A;
<br />
<br /><fl'-.r7-6.1}
<br />lJJ.2,6",,g,
<br />'?~..?3a
<br />
<br />~-""""""" ~.A..... 1..0000IJ00%
<br />Pl:mdhw<o~ .Pn>__ 0.2300000%
<br />Wodon t'Anij> Admini_ ~a.138gooO%
<br />
<br />AFh{OVUJ '\SO FORi"
<br />
<br />')
<br />I..,~.
<br />r;.- C<
<br />L' Vi rij Shecdy
<br />D put} City AttorJJcy
<br />
<br />
<br />,nl
<br />$161$
<br />111100
<br />
<br />~.
<br />
<br />;f71..?3a ."'A~
<br />
<br />1:982
<br />
<br />,;;;TQ.IaJ
<br />
<br />"2.720 ~~
<br />
<br />
<br />'1,000 TOCII.I~
<br />Ammal-..,
<br />
<br />'7 ,'738
<br />
<br />If"~~~18ofJll'lCmiumsttD.l1be:l'Dl.dc:Annl1a.l
<br />
<br />Cock.Ntrin~ OOOt.Q012G4
<br />~0fIire= .Lo. ~tU~/)-,l1.
<br />F~ No.; WCOll J()'93
<br />
<br />l:>.a
<br />
<br />C_;pOdby,
<br />
<br />~: lap:rU. U,. ~OQJ,"
<br />
<br />.DlIBnlIIIIIIIIIWIIlI'lIln,
<br />
<br />msu",d Copy
<br />
<br />'.'lllifllltllllltllilllillilllJ
<br />
<br />TmRL P.02
<br />
<br />
|