Laserfiche WebLink
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />Republic Underwriters Insurance Company <br />INFORMATION PAGE <br />WC040001A <br />(Ed. 7-98) <br />Policy No. ATW 005341-00 <br />Insurer ID No(s). 24538 Prior Policy No. <br />1. Named Insured: Miller & Pidskalny,Custom Woodwork (A Corp) <br />Individual LLC <br />Mailing Address: 1940 E. Blair Avenue x Corporation LLP <br />Santa Ana, CA 92705 Partnership Other: <br />FEIN: 33-0284783 <br />Intra/Interstate Risk ID No. 4328565 <br />Other workplaces not shown above: See Schedule of Locations <br />2. The policy period is from 08-16-2014 to 08-16-2015 12:01 A.M. standard time at <br />the insured's mailing address. <br />3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of <br />the states listed here: CA <br />B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3A. The <br />limits of our liability under Part 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: Part Three of the policy applies to the states, if any, listed Here: <br />NONE <br />D. This policy includes these endorsements and schedules: <br />See Scheduled of Forms <br />4. The premium forthis policy will be determined by our Manual of Rules, Classifications, Rates and Rating <br />Plans. All information required below is subject to verification and change by audit, <br />Code No. Classifications Premium Basis <br />Estimated Annual <br />Remuneration <br />See Schedule of Classifications <br />Experience Modification: <br />Minimum Premium: $750 <br />Premium Adjustment Period: <br />Rate Per Estimated <br />$100 of Annual <br />Remuneration Premium <br />Total Estimated Annual Premium: $42,527 <br />Deposit Premium: <br />Countersigned By: <br />Producer Information: RID Insurance Sales, Inc. DBA The Empire Company <br />550 North Park Center Drive, Suite 205, Santa Ana, CA 92705 <br />Servicing/Issuing Office: Atlas General Insurance. Services Date: _ 9/19/2014 <br />4365 Executive Drive; Suite 400 <br />San Dieao, CA 92121 <br />Exhibit C <br />