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<br />10/23/2001 15:13 <br /> <br />7146470209 <br /> <br />AL SANTA ANA <br /> <br />PAGE' , '~e2:) =;~<.. <br /> <br />.. <br /> <br /> <br />'-' <br /> <br />,.- <br />\ ..., <br /> <br />'-- <br /> <br />CLARENDON NATIONAL INSURANCE COMPANY <br />1177 Avenue of the A..erlcu <br />40ItII and 4StII FIG.", <br />N_ York, N.... Yorir. lQ036 <br />Carrier F.E.LN.: $!~ <br />INFORMATION PAGE NCCl Carrier ~l <br /> <br />Polley No.' SCTQT006600601 <br />R.eIIewoil of: <br /> <br />-.. .'" <br /> <br />I. <br /> <br />lb. 1"'''''<'<1: <br /> <br />A"I.st'tt&ocoe League of Sa.tit. Ana <br /> <br />FEIN: 9S11269tn <br />RISK: 0053<<5 <br />SIC CODE: 83 <br /> <br />Mailing a<ld.rt>.,;: 1031 W, Fin:!. SI. <br />Santa Ana, CA 92703 <br /> <br />Other w<.Jricph1e.. not .hown all"".: <br />See Endorsement III <br /> <br />Individual <br />X Cnrporation <br /> <br />Par1:1Iaship <br />Odtor <br /> <br />2. The poli")' period i. from lIIiIOI1:tOOl to O6IOl/ZOlq at the insur<>d'. mAiling address. <br /> <br />3. A. Wor\<mo' Compensation lnsunmc.: Port Oae oflbe policy applio.liO the Worla:r.' Compcn.sation Law <br />of the ...."'" listed hcie: CALIFORNIA (04) <br /> <br />B. Employe,," Liability WIInIIl"": Part Two of tho policy opplics to work in ellCh state listed in iIIom 3.A. <br />The limits of our liability under :>m Two are: <br /> <br />,-," <br /> <br />Bodily Injwy by Accident <br />Bodily Injury by 0;..- <br />Bodily Injuly by rn.e- <br /> <br />$1,000,_ <br />51,000,00II <br />$1,000,000 <br /> <br />each accident <br />policy limit <br />each ertljlloyoe <br /> <br />C Olhor States' Insunmce: Part Tbrec of tho policy opp1ies to the states, if my , lur.d horo:: <br /> <br />ALL STAlES NOT LISTED IN ITEM 3.A EXCEPT, NORm DAKOTA. OIDO, WASlIINQTON, <br />WEST VlRGlNlA, &: wYOMING <br /> <br />D. This policy includes these endorncmenlS and schedules: <br />we o.OlGIA. we 040310, WC o.lI6OtA, Endorsement 01 <br />CLARENDON NATIONAL INSURANCE COMl'ANY is required by taw to provide Its policyholders lrirlll <br />certain aeddent prevention ..tylces 85 roquired by Texa. Labor Code, s.ctlon 4lt.066, at no addltiona!' <br />charge. l( you would like more Information adl (800) 533-<<4ll. If you h..,e coy 'Iuestlon5 about thi> .. <br />requirerneu4 t,;ulI the Division or Worker', Health and s.rety, TCX8~ WOf'keN.' Compensation Commi5.iioJi III [ . <br />1-800-452-9595. I <br /> <br />Servicing Omce Stirlllu. Cooke Toxa.s. Inc. <br />5400 LBJ Prwy Suite 88fJ <br />Dallas, Tx 75240 <br /> <br /> <br />'-/ <br /> <br />WCOOOO01A <br />