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C1iJggClC]pf Workers' Compensation and Employers' Liability Policv [Employer ALIFORDEMNrrY INSURANCE C HOME OFFICE - BURBANK, CALIFORNIA ATIONS Policy _ 2912A amed Employer and Address; (No., Street, Town, County, State, Zip Code) Number: N ISK , WILLIAM ( HUSBAND) ISK, AMELIA ( WIFE ) DBA ) SAN JOAQUIN CITY RESORT & DELI 0836 S . AIRPORT WAY RACY CA 95376 is: NN ll�1 TT ��pp Renews No.licy 0,od: oo.'DayYr) N E W, standard time as to each of said dates. 1 /01 /89 to 1 /01 /90 Number 4- 500002-00- 1000 RONALD E . RAVETTI INS . SERVICE ITEM 3 Locations-All usual workplaces of the insured at or from which operations covered by this policy are conducted are located at the above address unless otherwise stated herein: ITEM 4 Code NOS. ESTIMATED RATE PER ESTIMATED CLASSIFICATION OF PRINICIPAL OPERATIONS ANNUAL $100 OF ANNUAL REMUNERATION REMUNERATION PREMIUM 8061 STORES--GROCERIES AND PROVISIONS-- 15 , 000 8 . 94 1 , 341 CONVENIENCE--RETAIL . EAP 1 , 341 ENDORSEMENT ATTACHED 1 . E06 2 . E02 3 . E01 The language of the classification or classifications of operations inserted in the policy declarations shall not be interpreted to extend insurance, or obligate the Company to the payment of benefits, to any person who is excluded from insurance by express statement elsewhere in this policy or in any endorsement hereto. OTHER OPERATIONS: proper classifications and rates to be determined in accordance with the manual in use by the Company. ITEM 5 The following persons are specifically covered as employees, anything in the Policy Exclusions to the contrary notwithstanding. ALL EXCLUSIONS APPLICABLE ITEM 6 Minimum Premium: $ 1 , 000 Deposit Premium: 5 1 , 341 + 13** ITEM 7 Payroll reporting and premium adjustment period: ANNUAL ITEM 8 Limit of Liability Coverage B — Employers Liability $1,000,000.00 Countersigned at BURBANK on 1 / 17/89 G By AUTHORIZED REPRESENTATIVE N 2912A ** STATE GUARANTEE FUND LAW FORM UND-6201 (11-67)