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NAICC STANDARD WORKERS COMPENSATION <br /> NATIONAL AMERICAN INSURANCE AND EMPLOYERS LIABILITY POLICY <br /> COMPANY OF CALIFORNIA INSURED COPY <br /> INFORMATION PAGE-RENEWAL <br /> POLICY NUMBER FROM POIAC'Y PERIOD TO AGENT <br /> 10 WC2 0011206 E 102/01/1995 102/01/1996 42 - 421 00100 <br /> NAMED INSURED AND ADDRESS <br /> fEM PAYDIRT EXCAVATING COMPANY, INC. S.N. POTTER INSURANCE AGENCY, INC. <br /> L. (A CORP. ) <br /> 269 OREGON P.O. BOX 7187 <br /> RIPON, CA 95366 STOCKTON, CA 95267 <br /> NO ADDITIONAL LOCATIONS PRIOR POLICY NUMBER SF WC 2 0011206 D <br /> ENTITY OF INSURED - CORPORATION <br /> 2. POLICY PERIOD- 02/01/1995 TO 02/01/1996 12.01 AM STANDARD TIME AT THE ADDRESS OF THE <br /> INSURED AS STATED HEREIN. <br /> 3A, WORKERS COMPENSATION INSURANCE:PART ONE OF THE POLICY APPLIES TO THE WORKERS COMPENSATION <br /> LAW OF THE STATES LISTED BELOW: <br /> CA. <br /> 3B. EMPLOYERS LIABILITY INSURANCE:PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED <br /> IN ITEM 3A. THE 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 /> 3C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO THE STATES, IF ANY, LISTED <br /> HERE: <br /> ALL STATES EXCEPT NEVADA, NORTH DAKOTA, OHIO, WASHINGTON, WEST VIRGINIA, WYOMING, STATES <br /> DESIGNATED IN ITEM 3A OF THE INFORMATION PAGE AND STATE(S) ADDED BY ENDORSEMENT. <br /> SEE ATTACHED SCHEDULE FOR LIST-OF ENDORSEMENTS-FORMING-PART OF-THIS POLICY. <br /> - - - - - - - - <br /> 4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, CLASSIFICATIONS, <br /> RATES, AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION AND <br /> CHANGE BY AUDIT. <br /> ADJUSTMENT OF PREMIUM SHALL BE MADE UPON POLICY EXPIRATION. <br /> CLASSIFICATION OF OPERATIONS EST RATE EST <br /> ST LOC CODE TVP TOT-ANN PER $100 ANNUAL <br /> NO RSK REMUN REMUN PREMIUM <br /> SEE ATTACHED SCHEDULE 1,340 <br /> OTHER PREMIUM ADJUSTMENTS (SEE ATTACHED SCHEDULE) 5 <br /> MINIMUM PREMIUM: $1,500 EXPENSE CONSTANT 160 <br /> TOTAL ESTIMATED ANNUAL PREMIUM 1,505 <br /> DEPOSIT PREMIUM 1,505 <br /> COUNTERSIGNED THIS DAY OF ,19 <br /> POLICY ISSUING OFFICE SAN FRANCISCO AUTHORIZED REPRESENTATIVE <br /> ISSUE DATE 02/23/1995 WC 00 00 O1 <br /> Includes Copyright mabrial of the National Council on Compensation Insurance,used wNh Its permission,Copyright 1118 National Council on Compensation Insurance. <br />