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w <br />365 5 (policy Provisions: WC 00 00 00 E) <br />Gs INFORMATION PAGE <br />WEG WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY <br />INSURED: SEE ATTACHED ENDORSEMENT <br />NCCI Company Number: 20505 <br />Company Code: S' <br />POLICY NUMBER: 1 76=WEG GE3565 <br />Previous Policy Number: 176 WEG GB3565 <br />HOUSING CODE: 76 <br />1. Named Insured and Mailing Address: BENCHMARK INTERNET GROUP LLC <br />(No., Street; Town, State, Zip Codoj <br />FEIN Number: 203553119 <br />State Identification Number(s); <br />10621 CALLS LEE <br />LOS ALAMITOS, CA 90720 <br />The Named Insured is- LIMITED LIABILITY COMPANY <br />Business of Named Insured: CUSTOM COMPUTER PROGRAMMING & <br />Other Workplaces not shown above: SEE ATTACHED SCHEDULES <br />2. Policy Period: From `12/07L14 To '12/01/15 <br />12:01 a.m., Standard tinge at the insured's mailing address, <br />Producer's Name: AP INTEGO INSURANCE GROUP LLC <br />PO, BOX 33015. <br />SAN ANTONIO, TX 78265 <br />Producer's Code:. 250846 <br />Issuing Office; THE HARTFORD <br />3600 WISEMAN BLVD, <br />SAN ANTONIO TX 78251 <br />Total Estimated Annual Premium - <br />Suffix <br />LARS R NEWAL <br />1. 01 <br />$750 CAA (INCLUSES INCREASED LIMIT MIN., PREM.) <br />Audit Period: ANNUAL Installment Term: <br />The policy is not binding unless countersigned by our authorized representative, <br />Countersigned by Lfu� _ ao `` `� 10./11/14 <br />Autnorized Representative. Date <br />Form DVC 00 00 01 A (1) Printed in U.S.A. Paige 1 (Continued on next page) <br />Process Slate: 10/11/14 Policy Expiration D^tei: 12/0 � 15' <br />ORIGINAL <br />-- C-�r-:�> 0 <br />