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0820;2008 01:03 FA% 719 973 7902 <br />t~oo9 <br />WORKERS COMPENS~NFDRMATbONMPAGEERS LIABILITY POLICY <br />23-3199-F419 ""'"`i <br />POLICY N0. 92-BF-B518-6 COTATEAGFARM FIREIAN~ CASUALTY COMPANY <br />900 OLD RIVER Rp, BAKERSFIELD CA 93311-6000 <br />NCCI CARRIER CODE N0. 14842 <br />NAMED INSURED & MAILING ApDRESS <br />MARTINEZ, REUBEN FEIN 205307777 <br />IDBAI REUBEN MAR7INEZ LEAP LOCATION: <br />1200 N MAIN ST STE 1000 1200 N MAIN ST STE 1000 <br />SANTA ANA CA 92701-3610 SANTA ANA CA 92701-3610 <br />INSURED IS NON PROFIT <br />COPYRIGHT 1987 NATIONAL COUNCIL ON COMPENSATION INSURANCE <br />2. ATETH~LINSUREDIODMAILINbGMADDRESS?008 TO 06/19/2009 12.01 A.M. STANDARp TIME <br />3A. WORKERS-COMPENSATION LAWUOFNT~E STATE~NLI~TEDHHEROLTCCAAPPIIES 70 THE <br />B. EMPLOYERS LIABILITY INSURANCE: PART TWO OF THE POLICY APPLIES TO <br />WORK IN EACH STATE LISTED IN ITEM 3A. THE LIMITS OF OUR LIABILITY <br />UNDER PART TWO ARE: BODILY INJURY BY ACCIDENT $1.000p,000 EACH ACCIDENT <br />BODILY INJURY BY DISEASE $1,000 000 POLICYMLIMI7E <br />C. OTHER STATES INSURANCE; PART THREE OF THE POLICY APPLIES TD ALL STATES <br />EXCEPT ME, MT, Np, OH, RI, WA, WV, WY AND STATES LISTED IN 3A. <br />D. THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES: WCOOOOOOA <br />WC040407 WC040360A WC040301A WC040601A W0000404 WC040104 WC040416 <br />4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF <br />RULES, CLASSIFICATTDNS RATES AND RATING PLANS. ALL INFORMATION <br />REQUIRED BELOW IS SUBJL`CT TD VERIFICATION AND CHANGE BY AUDIT. <br />PREMIUM BASIS TO- RATE/$100 ESTIMATED <br />CODE NOS. ANp TAL ESTIMATED AN- REMUNERA- ANNUAL <br />CLA55IFICATIONS NUAL REMUNERATION 7ION PREMIUM <br />8868 100,000 1.52 1,520 <br />COLLEGES OR SCHOOLS - PRIVATE - NOT <br />AUTOMOBILE SCHOOLS - PROFESSORS <br />TEACHERS OR PROFESSIONAL EMPLDY~ES <br />EMPLON~RSULIABI~ITYDLIMI7SEASED <br />FOREIGN TERRORISM PREMIUM 9740 <br />~*d <br />100,000 .03 <br />115 <br />30 <br />MINIMUM PREMIUM S 250 CALIFORNIA TOTAL ESTIMATED ANNUAL~PREMIUM $~ 1,665 <br />PREMIUM ADJUSTMENT PERIOD SHALL BE ANNUAL DEPOSIT PREMIUM $ 1,665 <br />STATE FRAUp SURCHARGE $ 4.00 <br />PREPARED 07/22/2008 OONTERSIGRGp OVERFLOW PAGE Q ~~ ~$ <br />WC 00 00 O1 04-84 BY AGEN <br />