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Liabi /ity /nsu�ance <br />Dec /arations <br />Effective Date SEPTEMBER 18, 2012 <br />Po /icy Number 3587 -79 -16 NBO <br />Liabi /ity Coverage <br />(continued) <br />STATE: CALIFORNIA <br />EMPLOYEE BENEF /TS <br />CLASSIFICATION CODE NUMBER: O O 17 6 <br />CLASSIFICATION DESCRIPTION: <br />E1��LOYEE BENEFITS E8cO <br />PREMIi7M BASIS: <br />NUMBER OF EMPLOYEES: 2 , 8 O 6 <br />RATE: 0.168 <br />Reference Copy <br />Liabi /ity /nsurance /ssue Date: SEPTEMBER 18, 2012 /ast page <br />Form 80 -02 -0010 (Ed. 4 -94) Declarations Paga 3 <br />