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• w <br /> THE MISSION INSURANG..COMPANIES STANDAF WORKERS COMPENSATION <br /> AND EMP*rbYERS LIABILITY POLICY <br /> INSURED COPY <br /> INFORMATION PAGE- NEW POLICY <br /> POLICY • • • IN THE AGENCY <br /> 0017 <br /> NAMED INSURED AND ADDRESS <br /> [TEM TRIPLE P. FEEDS, INC. ANDREINI & COMPANY <br /> 1 . 9556 SPRINGFIELD WAY <br /> STOCKTON, CA 220 W 20TH AVENUE <br /> 95212 SAN MATED CA 94403 <br /> NO ADDITIONAL LOCATIONS <br /> ENTITY OF' INSURED - CORPORATION <br /> 2. POLICY PERIOD- 03/09/86 TO 03/09/87 12.01 AM STANDARD TIME AT <br /> THE ADDRESS OF THE INSURED AS STATED HEREIN. <br /> 3A. WORKERS COMPENSATION INSURANCE : PART ONE OF THE POLICY APPLIES TO THE WORKER <br /> COMPENSATION LAW OF THE STATES LISTED HERE : <br /> CA. <br /> 3B. EMPLOYERS LIABILITY INSURANCE : PART TWO OF THE POLICY APPLIES T'0 WORK IN EACH <br /> STATE LISTED IN ITEM 3A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE: <br /> BODILY INJURY BY ACCIDENT $100, 000 EACH ACCIDENT <br /> BODILY INJURY BY DISEASE $500,000 POLICY LIMIT <br /> BODILY INJURY BY DISEASE $100, 000 EACH EMPLOYEE <br /> 3C. OTHER STATES INSURANCE : PART THREE OF THE POLICY APPLIES TO THE STATES, IF <br /> ANY, LISTED HERE : <br /> ALL STATES EXCEPT NEVADA, NORTH DAKOTA, OHIO, WASHINGTON, WEST VIRGINIA, <br /> WYOMING, STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE AND STATE(S) <br /> ADDED BY ENDORSEMENT. <br /> :EE ATTACHED SCHEDULE FOR LIST OF' ENDORSEMENTS FORMING FART OF' THIS POLICY. <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> 4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, <br /> CLASSIFICATIONS, RATES, AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS <br /> SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. <br /> ADJUSTMENT OF PREMIUM SHALL_ BE MADE ANNUALLY. <br /> CLASSIFICATION OF OPERATIONS EST RATE EST <br /> ;T LOC CODE TYP TOT-ANN PER $100 ANNUAL <br /> NO RSK REMUN REMUN PREMIUM <br /> SEE ATTACHED SCHEDULE 1 , 095 <br /> MINIMUM PREMIUM $750 EXPENSE CONSTANT 0 <br /> TOTAL ESTIMATED ANNUAL PREMIUM $1 , 095 <br /> DEPOSIT PREMIUM $750 <br /> :OUNTERSIGNED THIS 24TH DAY OF FEBRUARY 19 86 - - - - - - - - - - - - - - <br /> 'OI_ICY ISSUING OFFICE SAN FRANCISCO AUTHORIZED REPRESENTATIVE <br /> ISSUE DATE 02/12/86 56001 ( 11 /85) <br /> 629J8nim <br /> 111-851 <br />