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WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INFORMATION PAGE INSURED IS A CORPORATION COPYRIGHT 1987 NATIONAL COUNCIL ON COMPENSATION INSURANCE ------------ -- ------------------- - 2. THE POLICY PERIOD IS FROM 09/01/2010 TO 09/01/2011 12:01 A.M. STANDARD TIME AT THE INSURED'S MAILING ADDRESS. ---------- ------------------ --------- --------------- ----- 3A. WORKERS COMPENSATION INSURANCE: PART ONE OF THE POLICY APPLIES TO THE WORKERS COMPENSATION LAW OF THE STATES LISTED HERE: CA B. EMPLOYERS LIABILITY INSURANCE: PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3A. THE LIMITS OF= OUR LIABILITY UNDER PART TWO ARE: BODILY INJURY BY ACCIDENT $1,000,000 EACH ACCIDENT BODILY INJURY BY DISEASE $1,000,000 EACH EMPLOYEE BODILY INJURY BY DISEASE $1,000,000 POLICY LIMIT C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO ALL STATES EXCEPT ME, MT, ND, OH, RI, WA, WV, WY AND STATES LISTED IN 3A. D. THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES: WCOOOOOOA WC040360A WC040301A WC000404 FE -4893 WC040601A WC040104 WC040416 4 THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, CLASSIFICATIONS, RATES AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. ----------------------------------------- -- -- -- ----- PREMIUM BASIS TO- RATE/$100 ESTIMATED CODE NOS. AND TAL ESTIMATED AN- REMUNERA- ANNUAL CLASSIFICATIONS NUAL REMUNERATION TION PREMIUM --------------------------- ---- ---------- --------- --------- 8810 60,000 .92 552 CLERICAL OFFICE EMPLOYEES - NOC COMPANY SURCHARGE FOR INCREASED 115 EMPLOYERS LIABILITY LIMITS A,PPiZUVED AS T® FORM L ura-5t.1u S':�eedY Assistant City �tcorney ray TERRORISM 9740 I 60,000 I .03 I 18 MINIMUM PREMIUM $ 250 CALIFORNIA TOTAL ESTIMATED ANNUAL PREMIUM $ 685 PREMIUM ADJUSTMENT PERIOD SHALL BE ANNUAL DEPOSIT PREMIUM $ 685 STATE FRAUD SURCHARGE $ 3.00 CHA PREPARED 06/23/2010 COUNTERSIGNED OVERFLOW PAGE WC 00 00 01 04-84 }r 80 2272 3677 BY AGENT 23-8290-F418 - POLICY NO. 92 -BP -T509-0 COVERAGE IS PROVIDED BY REPLACES NO. 92 -BJ -L190-8 STATE FARM FIRE AND CASUALTY COMPANY 900 OLD RIVER RD, BAKERSFIELD CA 93311-6000 NCCI CARRIER CODE NO. 14842 1 NAMED INSURED & MAILING ADDRESS ELIZABETH M KILEY INC FEIN 010640526 (DBA) KILEY COMPANY LOCATION: 2681 DOW AVE STE E 2681 DOW AVE STE E N-2010-07 TUSTIN CA 92780-7244 TUSTIN CA 92780-7244 2 INSURED IS A CORPORATION COPYRIGHT 1987 NATIONAL COUNCIL ON COMPENSATION INSURANCE ------------ -- ------------------- - 2. THE POLICY PERIOD IS FROM 09/01/2010 TO 09/01/2011 12:01 A.M. STANDARD TIME AT THE INSURED'S MAILING ADDRESS. ---------- ------------------ --------- --------------- ----- 3A. WORKERS COMPENSATION INSURANCE: PART ONE OF THE POLICY APPLIES TO THE WORKERS COMPENSATION LAW OF THE STATES LISTED HERE: CA B. EMPLOYERS LIABILITY INSURANCE: PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3A. THE LIMITS OF= OUR LIABILITY UNDER PART TWO ARE: BODILY INJURY BY ACCIDENT $1,000,000 EACH ACCIDENT BODILY INJURY BY DISEASE $1,000,000 EACH EMPLOYEE BODILY INJURY BY DISEASE $1,000,000 POLICY LIMIT C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO ALL STATES EXCEPT ME, MT, ND, OH, RI, WA, WV, WY AND STATES LISTED IN 3A. D. THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES: WCOOOOOOA WC040360A WC040301A WC000404 FE -4893 WC040601A WC040104 WC040416 4 THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, CLASSIFICATIONS, RATES AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. ----------------------------------------- -- -- -- ----- PREMIUM BASIS TO- RATE/$100 ESTIMATED CODE NOS. AND TAL ESTIMATED AN- REMUNERA- ANNUAL CLASSIFICATIONS NUAL REMUNERATION TION PREMIUM --------------------------- ---- ---------- --------- --------- 8810 60,000 .92 552 CLERICAL OFFICE EMPLOYEES - NOC COMPANY SURCHARGE FOR INCREASED 115 EMPLOYERS LIABILITY LIMITS A,PPiZUVED AS T® FORM L ura-5t.1u S':�eedY Assistant City �tcorney ray TERRORISM 9740 I 60,000 I .03 I 18 MINIMUM PREMIUM $ 250 CALIFORNIA TOTAL ESTIMATED ANNUAL PREMIUM $ 685 PREMIUM ADJUSTMENT PERIOD SHALL BE ANNUAL DEPOSIT PREMIUM $ 685 STATE FRAUD SURCHARGE $ 3.00 CHA PREPARED 06/23/2010 COUNTERSIGNED OVERFLOW PAGE WC 00 00 01 04-84 }r 80 2272 3677 BY AGENT