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Workers' Compensation and Employer's Liability Policy <br />GUARDAmGUARD Insurance Company - A Stock Company <br />f ( Dr R IVtaIS Policy Number ORWC311495 <br />0U� Renewal of OR 13 <br />NCCI No.[2180.[21873] <br />Policy Information Page <br />[1] Named Insured and Mailing Address Agency <br />Orange County Asian and Pacific Islander Community PAYCHEX INSURANCE AGENCY <br />Alliance 150 Sawgrass Drive <br />12900 GARDEN GROVE BLVD Rochester, NY 14620 <br />SUITE 214A Agency Code: NYPAYCIO <br />GARDEN GROVE, CA 92843 <br />Federal Employer's ID 91-2047245 Insured is Non -Profit <br />Additional Names of Insured - See Extension of Information Page - <br />Schedule of Named Insured - WC 040002 <br />[2] Policy Period <br />From October 08, 2012 to October 08, 2013, 12:01 AM, standard time at the insured's mailing address. <br />[3] Coverage <br />A. Workers' Cornpensadon Insurance - Part. One of this policy applies to the Workers' Compensatlon <br />Law of the following states: California <br />B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed <br />in item [3]A: The limits of our liability under Part Two are: <br />Bodily Injury by Accident - each accident $1,000,000 <br />Bodily Injury by Disease - each employee $1,000,000 <br />Bodily Injury by Disease - policy limit $1,000,000 <br />C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in <br />item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming. <br />D. This policy includes these endorsements and schedules: <br />See Extension of Information Page - Schedule of Forms - WC 040004 <br />-[4]- Premium <br />The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, <br />Classifications, Rates, and Rating Plans. All required information is subject to verification and change by <br />audit. (Continued on another page) <br />Total Estimated Policy Premium <br />Total Surcharges/Assessments <br />Total Estimated Cost <br />792 <br />34 <br />826 <br />C S G ORCK <br />a.ISla }City Attorne4 <br />ONTERNAL use Xx Page - 1 - information Page <br />MGA :ORWC311495 WC 000001A <br />Date :09/D8/2C.2 <br />16 South River Street. P,O, Box A-H • Wilkes-Barre, PA 18703-0020 • www.guard.com <br />