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INFORMATION PACE (Continued) <br />Policy Number: 76 WEG GB3565 <br />3. A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the <br />states listed here: CA, IL, NY <br />B, Employers Liability Insurance: Part Two of the policy applies to work in each state listed In Item 3.A: <br />The limits of our liability under Pail Two are: <br />Bodily injury by Accident $1,000,000 each accident <br />Bodily injury by Disease $1,000,000 policy limit <br />Bodily injury by Disease $1"000'000 each employee <br />C. Other States insurance: Pad Three of the policy applies to the states, If:any, listed here:: <br />ALL STATES EXCEPT ND, OH, WA, WY, AND <br />STATES DESIGNATED IN ITEM 3,A, OF THE INFORMATION PAGE, <br />D, This policy includes these endorsements and scheduler <br />WC 99 00 05 WC 00 01 14 WC 00 04 21C WC 00 04 22A WC 04 03 03 <br />SEE ENDT <br />4, The <br />Classifications Total Estimated Rates Per <br />Coda Number and, Annual $160 of <br />($SE ATTACHED SCHEDULES,) <br />INCREASEDD, LIMITS PART TWO (9912) <br />TO EQUAL 'INCREASED LIMITS. MINIMUM PREMIUM (9648) <br />CA 'TERRITORIAL DIFFERENTIAL PREMIUM T125 (1.050) <br />TOTAL PREMIUM SUBJECT TO EXPERIENCE MODIFICATION <br />PREMIUM ADJUSTED BY: APPLICATION OF EXPERIENCE MODIFICATION <br />CA SMALL POLICY CREDIT <br />TOTAL ESTIMATED ANNUAL STANDARD PREMIUM <br />EXPENSE CONSTANT (0400) <br />TOTAL ESTIMATED STATE SURCHARGE <br />TERRORISM (9740) <br />TERRORISM (9740) PER CAPITA <br />CATASTROPHE (9741) <br />CATASTROPHE (9741) PER CAPITA <br />TOTAL ESTIMATED ANNUAL PREMIUM <br />Rates and Rating <br />1 <br />149 <br />59 <br />6.0' <br />55 <br />^115: <br />1,363 <br />M <br />73 <br />179 <br />0 <br />5 <br />0 <br />1,921 <br />Total Estimated Annual Premium: $1,921 <br />Deposit Premium; <br />Policy Minimum Premium: $750 CA (INCLUDES INCREASED LIMIT MIN. PREM,) <br />Interstate/Intrastate Identification Number: <br />Labor Contractors Policy Numbers <br />Form WC 00 00 01 A (t) Printed in U.S,A. <br />Process Date: 10/11/14 <br />/ 001109478 <br />NAICS: <br />SIC; 737 V b-4071 , , , g1,�- <br />W �dU (J <br />Page 2 <br />Policy Expiration Date: 12/01/15 <br />