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EXTENSION OF THE INFORMATION PAGE - ITEM 3.D - ENDORSEMENTS <br />Policy Number: 72 WEC GG6484 Endorsement Number: <br />Effective Date: 08/20/19 Effective hour is the same as stated on the Information Page of the policy. <br />Named Insured and Address: SUDABEH SHOJA <br />23232 PERALTA DR, SUITE 112 <br />LAGUNA HILLS CA 92653 <br />Item 3.D. of the Information Page is completed to include the following endorsements: <br />WC000000C <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC000001A.1 <br />INFORMATION PAGE <br />WC000001A.2 <br />INFORMATION PAGE <br />WC000422B <br />TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE <br />ENDORSEMENT <br />WC040301 BB <br />POLICY AMENDATORY ENDORSEMENT - CALIFORNIA <br />WC040306 <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - <br />CALIFORNIA <br />WC040360B <br />EMPLOYERS LIABILITY COVERAGE AMENDATORY ENDORSEMENT - CALIFORNIA <br />WC040421 <br />OPTIONAL PREMIUM INCREASE ENDORSEMENT - CALIFORNIA <br />WC040422 <br />CALIFORNIA SHORT -RATE CANCELLATION ENDORSEMENT <br />WC040601A <br />CALIFORNIA CANCELLATION ENDORSEMENT <br />WC550011 D <br />Employees Claim for Workers compensation Benefits <br />WC8804001 <br />Notice to Employees - Injuries Caused By Work (TITLE IN SPANISH) <br />WC8804011 <br />Notice to Employees - Injuries Caused By Work <br />WC9900011 <br />Signature/ Copyright <br />WC990002 <br />WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY BUSINESS INSURANCE <br />POLICY <br />WC990005 <br />SCHEDULE OF OPERATIONS <br />WC990302B <br />WORKERS COMPENSATION BROAD FORM ENDORSEMENT <br />Form WC 99 03 68 Printed in U.S.A. <br />Process Date: 07/11/19 Policy Expiration Date: 08/20/20 <br />