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STANDARD <br />WORKERS' COMPENSATION AND <br />EMPLOYERS' LIABILITY POLICY <br />INFORMATION PAGE <br />ITEM 1. <br />The Insured PULMONARY CONSULTANTS OF OC <br />Mailing Address 1310 W STEWART DR #410 <br />ORANGE, CA 92868 <br />Other workplaces not shown above <br />Individual Partnership <br />X Corporation or <br />ITEM 2. The policy period is from 10101106 to 10/01/07 <br />Employers Compensation <br />Insurance Company <br />P.O. BOX 9057, Oxnard, CA 93031 <br />(800) 520 -1683 <br />POUCY <br />NUMBER: SM81 -1006 -10378 <br />RENEWAL OF: SL81- 1005 -10378 <br />PRODUCER <br />CODE STATEJ <br />AB <br />Rate <br />04814495 <br />1250 <br />04 J <br />16 <br />Per 5100 of <br />Producer OMEGA INSURANCE SERVICES, INC. <br />Name and 721 S. PARKER STE 300 <br />Address (WORD & BROWN) <br />ORANGE, CA 92865 <br />12:01 A.M., standard time at the insured's mailing address. <br />ITEM 3. A. Workers' Compensation Insurance: Pail One of the policy applies to the Workers' Compensation Law of the states listed here: <br />CALIFORNIA <br />S. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3A <br />The limits of our liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident <br />Bodily Injury by Disease $ 1,000,000 policy limit <br />Bodily Injury by Disease $ 1, 000, 000 each employee <br />C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: <br />NONE <br />D. This policy includes these endorsements and schedules: (WC -) <br />040301P, 990308A, 990638B, 990316A, 040407, 000113, 000422, 990428, <br />990302B. PN049901C, PN049902B, PN999904C <br />ITEM 4. Classification <br />Code No. <br />Premium Basis <br />Rate <br />The hrermum for this policy vrig be aeten. ned by our Manuals of Rules. aassficalions. Rates and Raing <br />Estimated <br />Per 5100 of <br />Estimated Annual <br />Plans. All informaion required below is subject w vefff ®lion and Change by audit. <br />Annual R nnuneradon <br />Remuneration <br />. Premum <br />(SEE EXTENSION SCHMLTihE) <br />Normal Anniversary Date <br />Experience Modification 70 $ <br />-13,496 <br />B.N.: 163 67 63R <br />952870308 <br />Minimum Premium $ 750 Total Estimated Annual Premium $ 38,687 <br />If indicated herein, interim adjustments <br />of premium shall be made Semi - Annually 0 Quarterly 7 Monthly ❑ Deposit Premium $ 4,749 <br />NEWB <br />Issued at IJRY PARK Deposit Paid By Transfer <br />Carrier. 00441 <br />Date 09/08106 Countersigned By <br />WC 49 04 40 A (10 -II3) <br />Aulh=Ld RepresentativeC <br />