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• r NCCI# 15458 Oak River Insurance Company WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY This information page with'Policy Provisions"completes the below numbered Insured's Name and Mailing Address-ITEM 1 Policy No.FOWC012986 Fox Loomis, Inc. 6901 McComber Street Renewal Or Rewrite Of No.FOWC910300 Sacramento,CA 95828 Agent:CAH01000 HUB INTERNATIONAL INSURANCE SERVICES INC. 3636 American River Dr Ste 200 Sacramento,CA 95864 Other Workplaces, not shown above: SEE LOCATION SCHEDULE ATTACHED issue Date:09/27/2019 Servicing Office:San Francisco Federal Employer I.D. No.94-2605464 Bureau I.D.No. 2200800 Effective-ITEM2: From: 10/01/2019 To: 10/01/2020 at 12:01 A.M.Standard Time at the insured's mailing address Form of Business: ❑ Individual ❑ PartnershipX❑ Corporation ❑ Joint Venture ❑ Other Coverage - ITEM3: A. Workers compensation Insurance: Part One of the policy applies to the Workers compensation Law of the states listed here. CA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident $1,000,000 Each Accident Bodily Injury by Disease $1,000,000 Policy Limit Bodily Injury by Disease $1,000,000 Each Employee C. Other States Insurance: Part Three of the policy applies to the states, if any,listed here: All States Except:ND,OH,WA,WY D. This policy includes these endorsements and schedules: See Schedule Attached Premium-ITEM4: The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Total Rates Per Estimated Annual Classification Code Annual $100 of No. Premium Remuneration Remuneration See Schedule Attached Premium Adjustment Period:Monthly Total Estimated Annual Premium: WC 99 0312 (Ed.7-12)