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—�I PACIFIC EMPLOYERS INSURANCE COMFANY 1 <br /> I <br /> + ; WORKERS COMPENSATION AND EMPLOYERS INFORMATION PAGE <br /> LIABILITY INSURANCE POLICY <br /> fItems. I LEEDSHILL—HERKENHOFF, INC. PAG E __L.LA ST PAGE ) <br /> The 1275 MARKET STREET SYM POLICY NUMBER <br /> I Insured SAN FRANCISCO• CA 94103 1 C3 03 55 85 4 <br /> PRODUCER BILLED <br /> Mailing ❑Individual ❑Part"(stup <br /> _ Address L ®corpwation ❑ <br /> Other workplaces not shown above: PER INFCRMATION PAGE ATTACHED AUTOMATIC REG!, <br /> Item 2. Policy period frorn —01—CI-88 I to 01-01-89 12:01 A.M., standard time at the insured's mailing address.. <br /> TE Item 3.A Workers Compensation Insurance:Part One of tho policy applies to the Workers Compensation Law of the states listed he <br /> 01 PER INFCRNATIGN PAGE ATTACHED <br /> B. Employers Liability Insurance:Part Two of the policy applies to work in each state listed in Item 3. A. <br /> j The limits of our liability under Part Two are: Bodily Injury by Accident$ 1 C-0.000 each accident <br /> Bodily Injury by Disease $ 500+000 policy limit <br /> Bodily Injury by Disease $ 100,000 each em to ee <br /> C. Other States Insurance: Part Three of the policy applies to the states,if any, listed here: <br /> ALL STATES EXCEPT <br /> NV.ND.GH.NA.AV*WY*STATES 6>:S:IJG.NPAGE AIvOp <br /> Item 4. The premium for this policy will be determined by our Manuals of Rules,Classifications.Rates and Rating Plans. All informatiori <br /> required below is subject to verification and change by audit. <br /> I__� __.._. Classifications <br /> Premium Basis VRate <br /> ~—�— Code Estimated Total Pu$100 of Eatimetetl <br /> No. Annual Remuneration RamuneuGon Annual Premium <br /> U.S.L. C Fl. k. ACT CALIFCRNIA 160. <br /> CALIFCRNIA SURCHARGE <br /> CALIFCRNIA 11459. <br /> CALIFCRNIA SURCHARGE 120. <br /> COLORADO 563. I <br /> I <br /> I <br /> I <br /> I <br /> j Minimum Premium $ 850. COLLECTED IN CA Total Estimated Annual Premium $ 12743. <br /> If Indicated here, interim adjust- ( LAST PAGE ) <br /> monts of promium will be made: ❑ Semi-Annually 0 Quarterly ❑ Monthly %Deposit P(emium $ 4538. <br /> This policy includes these endorsements and schedules: CC 1 E 15 CKE3N09.�, <br /> Ac Employer's Identification No.: i+,J✓ti��fj�i 1 f �, �,r, .: <br /> SO Interstate Identification No.: Countersigned By <br /> - <br /> New- ED Renowg ❑ Rewrite of <br /> d <br /> ❑ mnori:ed Agentl <br /> T SYM PREv+DUSPOLICY No. PRODUCER: JCHNSCN C HIGGINS CA CENTER <br /> . GNG _C2875..953C. _._._ MARKETING OFFICE:..SAN—FRANGL.5C0._.. _ ._ 88022 CCG 6l3.6A SFS- <br /> + CKE-4266 Ptd i11U.5.4 CopVrinm1982HayonolCmaneem+Companaa+mnlnaaraoca. flprrlyAI WC 00 00 0 <br />