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TRAVELERS <br />1--.? <br />WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />TYPE V INFORMATION PAGE WC 00 00 01 ( A) <br />POLICY NUMBER: (IJUB-3802M53-1 -10) <br />RENEWAL OF (IACRUB-3802M53-1-09) <br />INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA <br />1. <br />INSURED: <br />PACIFIC TRAFFIC DATA SERVICES <br />8502 E. CHAPMAN #625 <br />ORANGE CA 92869 <br />Insured is A LIMITED LIABILITY COMPANY <br />PRODUCER: <br />NCCI CO CODE: 13579 <br />PAYCHEX INS AGENCY INC <br />150 SAWGRASS DRIVE <br />ROCHESTER NY 14620 <br />Other work places and identification numbers are shown in the schedule(s) attached. <br />2. The policy period is from 11 -27-10 to 11 -27-11 12:01 A.M. at the Insured's mailing address. <br />3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers <br />Compensation Law of the state(s) listed here: <br />CA ID NV <br />0= <br />o= <br />o= <br />o?. <br />o <br />o= <br />W. <br />B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in <br />item 3.A. The limits of our liability under Part Two are: <br />10 Bodily Injury by Accident: $ 1000000 Each Accident <br />Bodily Injury by Disease: $ 1000000 Policy Limit <br />Bodily Injury by Disease: $ 1000000 Each Employee <br />C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: <br />AL AR AZ CO CT DC DE FL GA HI IA IL IN KS KY LA MA MD ME MI MN MO <br />MS MT NC NE NH NJ NM NY OK OR PA RI SC SD TN TX UT VA VT WI WV <br />D. This policy includes these endorsements and schedules: <br />SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE <br />4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating <br />Plans. All required information is subject to verification and change by audit to be made ANNUALLY, <br />DATE OF ISSUE: 10-1 3-10 IA <br />OFFICE: PAYROLL 70A <br />PRODUCER: PAYCHEX INS AGENCY INC <br />SV996 <br />004272