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<br />-JUri .0:::"'+ VO u::J...)oa <br /> <br />I A~,=>A l....;UN~UL lING <br /> <br />916-444-0042 <br /> <br />p,3 <br /> <br />N <br /><:> <br />'" <br /><:> <br />'" <br /> <br />.-i <br />'" <br />.-i <br />'" <br />N <br />00 <br />'" <br /><:> <br />~ <br />en <br /><0 <br />'" <br />co <br />co <br />U'1 <br />'" <br />. <br /> <br />- <br /> <br />~ <br />- <br /> <br />- <br />- <br /> <br />-= <br /> <br />= <br />-= <br />-= <br /> <br />- <br />..... <br /> <br />- <br />= <br />- <br /> <br />INFORMATION PAGE (Continued) <br /> <br />Policy Number: 65 W,C NW0982 <br /> <br />3. A. Workers Compensation Insurance: Part one of Ihe policy applies to the Warke", Compensation Law of the <br />states listed here: CA <br /> <br />B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. <br />The limits of our liability under Part Two are: <br />Bodily injury by Accident <br />Bodily injury by Disease <br />Bodily injury by Disease <br /> <br />$1,000,000 <br />$1,000,000 <br />$1,000,000 <br /> <br />each accident <br />polic\, limit <br />each employee <br /> <br />C. other States Insurance: Part Three of the policy applies to the states. if any. lislr,d here: <br /> <br />ALL STATES EXCEPT NO, OH, WA, WY, AND <br />STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE. <br /> <br />D. This policy includes these endorsements and schedule: <br />WC 04 01 04 WC 04 03 03 we 04 04 16 WC 99 03 03B .]C' 04 Oil 03 <br />SEE ENDT <br /> <br />4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating <br />Plans. All information required below is subject to verification and change by audit. <br />Premium Basis <br />Total Estimated <br />Annual <br />Remuneration <br /> <br />Classifications <br />Code Number and <br />Description <br />8BlO <br />CLERICAL OFFICE <br /> <br />Rates Per <br />$100 of <br />Remuneration <br /> <br />Estimated <br />Annual <br />Premium <br /> <br />91,600 <br /> <br />.72 <br /> <br />660 <br /> <br />EMPLOYEES-N 0 C <br /> <br />CA TERRITORIAL DIFFERENTIAL PREMIUM 9694 10.950) <br />TOTAL ESTIMATED Am.'UAL STANDARD PREMIUM <br />TO EQUAL MINIMUM PREMIUK (0990) <br />':'OTAL ESTIMATE!) ANNUAL STANDARD PREMIUM <br />BROAD FORM - EXTENDED (9702) 1.50 PERCENT <br />CA SURCHARGE 2.000 PERCENT <br />USER FUNDING ASSESSMENT 1.0703 PERCENT <br />FRAUD ASSESSMENT 0.2394 PERCENT <br />CA UNINSD EMPL BENEFIT TRUST FUND 0.1730 PERCENT <br />CA SUBSEQ INJ BENEFITS TRUST FUND 0.0311 PERCENT <br />FOREIGN TERRORISM (9740) 91,600 <br />TOTAL ESTIM!\TED ANNUAL PREMIUM <br /> <br />.030 <br /> <br />.-33 <br />627 <br />373 <br />1,000 <br />9 <br />2:' <br />11 <br />2 <br />2 <br />o <br />27 <br />1,072 <br /> <br />Total Estimated Annual Premium: <br /> <br />Deposit Premium: <br />Policy Minimum Premium: $1,000 <br /> <br />$1,072 <br />$1,072 <br />CA (INCLUDES INCREASED LIMIT HIN. PREM. ) <br /> <br />InterstateJIntrastate Identirication Number: <br /> <br />Labor Contractors Policy Number: <br /> <br />NAICS: <br />SIC: 8111 <br />UIN: <br />NO. OF EMP: <br /> <br />000002 <br /> <br />Form we 00 00 01 A (1) Printed in USA <br />Process Date: 06/14/08 <br /> <br />Page 2 <br />Policy Expiration Date; 07/27/09 <br />