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4 <br />-&-,z-Arch <br />Insurance Grain <br />ARCH INSURANCE COMPANY <br />(A Missouri Corporation) <br />Home Office Address: <br />3100 Broadway, Suite 511 <br />Kansas City, MO 64111 <br />Administrative Address: <br />One Liberty Plaza, 53rd Floor <br />New York, NY 10006 <br />Tel: (800) 817 -3252 <br />SPECIFIC EXCESS WORKERS COMPENSATION AND <br />EMPLOYERS LIABILITY INSURANCE POLICY <br />DECLARATIONS <br />Policy Number: WCX 0055277 00 <br />Named Insured: Western Orange County Self- Funded Workers' Compe <br />Address: 200 Kalmus Drive, Room 1117, Costa Mesa California 92626 <br />Producer Name: Swett & Crawford of Woodland Hills <br />Address: 21650 Oxnard Street, Suite 1400, Woodland Hills California 91367 -4901 <br />Item 2: Policy Period: I Inception Date: I July 1, 2013 I Expiration Date: I July 1, 2014 1 <br />at 12:01 A.M. Standard Time at vour mailina address as <br />Item 3: This insurance applies to the Workers Compensation and Occupational Disease Laws of <br />the following states: California <br />Item 4: Premiums <br />Estimated Total Annual Remuneration: $ 218,245,927 <br />Rate per $100 of Remuneration: .1480 <br />Deposit Premium: $ 323,004 <br />(Terrorism Premium Included In Policy Premium ): $ 9,690 <br />Minimum Premium: $ 306,854 <br />Item 5: Your Retained Limit <br />prRt VED AS O FO RN', <br />Laura A. Rossini <br />Assistant City Attorney <br />Part One — Excess Workers Compensation Insurance and Part Two- Excess Employers Liability <br />Insurance: <br />Your Retained Limit of Liability — Each Accident $500,000 <br />Your Retained Limit of Liability — Disease, Each Employee $500,000 <br />05 GL0400 00 (01 08) Page 1 of 2 <br />