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NCCI No. 28916 <br />New No. <br />WC- 00- 00 -01A <br />SOUTHERN INSURANCE COMPANY <br />A STOCK COMPANY <br />5525 LEI FREEWAY <br />DALLAS, TEXAS 75240 -6241 <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />INFORMATION PAGE <br />Policy No, WSIO020579 -01 <br />Renewal of Policy Number New <br />State Unemployment I.D. No. or Identifying Number as Required: A.._.__ <br />ces <br />1. Insured: American Capital Enterprise, Inc. dba Produt °reran Insurance Servi 071184, Inc. <br />(868) 530 -5700 • D01 #0711841 <br />Mailing PO Box 893580 Mailir JORDAN PLA7A,STE 140.1325 AUTO PLAZA DR. <br />P.O. BOX 5276 •SAN BERNARDINO, CA 92412 -5276 <br />Address Temecula, CA 92589 -3580 Addre (909) 888 -2231 FAX (909) 889 -3428 <br />Individual 7 Partnership Corporation or <br />Other workplace not shown above: See Attached Location Schedule <br />2. Policy Period: The policy is from 06101/2009 to 06/01/2010 [12.01 AM Standard Time] at the insured's mailing address. <br />3. A. Workers Compensation Insurance: Part One of this policy applies to the Workers Compensation Law of the states listed here: <br />CALIFORNIA <br />B. Employers liability Insurance: Part Two of this policy applies to work in each state listed in Item 3A. The limits of our <br />liability under Part Two are: <br />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 this policy applies to the states, if any, listed here: <br />NO COVERAGE AFFORDED FOR OTHER STATES. <br />D. This Policy includes these endorsements and schedules: WC040002A, WC040003, WC040004, WC040005, WCINSTAL, <br />WCOOOOOOA, WC000419, WC000422A, WC040301A, WC040303, WC040360A, WC040407, WC040421, WC040601A, <br />PNO49901C, PN049902B, PNO49904, CALOSS <br />4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and <br />Rating Plans. All information required below is subject to verification and change by audit. <br />Code Premium Basis Total Rate Per <br />Classification No Estimated Annual $100 of Estimated Annual Premium <br />Remuneration Remuneration <br />See WC 04 00 05 Extension of Information Page <br />MINIMUM PREMIUM TOTAL ESTIMATED ANNUAL PREMIUM _ <br />TAXES & ASSESSMENTS _ <br />IF INDICATED BELOW, INTERIM ADJUSTMENTS OF PREMUIM SHALL BE MADE: <br />Semi - Annually X Quarterly Monthly S Deposit Premium $Per Installment Endr <br />Issuing Office: Omaha, Nebraska / <br />Countersigned by: <br />( ,(���'��:;- '�-- ✓l]'�, <br />SIC -WC -IP / <br />APPROVED AS TO FORM <br />..aura still s;,��d� <br />Assistant City Att<, 'icy <br />1 of <br />IIIIIIIIIIIIIIIIIIIIIIII6II�IIIIIIIIIIIIIIIIIIIIIII0111111111111111111111111 IIIIIIILIIIIIIIIIII�I�IiININIIIIIIIIIIIUIIIIIIIII9II1IINllllllll <br />