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C000001A <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br /> Information Page <br /> SERVICE AMERICAN INDEMNITY COMPANY , a stock company <br /> PO Box 26850 <br /> AUSTIN , TEXAS 78755 <br /> NCCI # 38369 <br /> Name of Producer: George Petersen Insurance Policy No . SAMTWC 0 0 7 0 3 0 0 <br /> Agency , Inc . 000663 Renewal of: NEW <br /> 175 W College Ave Individual Partnership <br /> Santa Rosa CA 95101 X Corporation or <br /> 1 . The Insured : Service Station systems , Inc . Federal Employers I . D .# See Schedule <br /> Inter/Intrastate Risk I .D .# 8 513 0 0R <br /> Other I . D . # <br /> Mailing address : 3224 Regional Parkway <br /> Santa Rosa , CA 95403 <br /> Other workplaces not shown above : See Schedule <br /> 2 , Policy Period : From 06 / 04 / 2021 To 06 / 04 / 2022 12 : 01 A. M . standard time at the insured's mailing address. <br /> 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states <br /> listed here : CA <br /> B . Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3 . A. The limits of <br /> our liability under Part Two are : Bodily Injury by Accident $ 2 0 0 OQ,, OQ O _ each accident <br /> Bodily Injury by Disease $ x,, 40Q OIlQ policy limit <br /> Bodily Injury by Disease $ 1 , 000 , 000 each employee <br /> C . Other States Insurance: Part Three of the policy applies to the states , if any, listed here: <br /> All states except North Dakota , Ohio , Washington , Wyoming , States designated in item 3A <br /> of the Information Page . <br /> D . This policy includes these endorsements and schedules : See Schedule <br /> 4 . The premium for this policy will be determined by our Manuals of Rules , Classifications , Rates and Rating Plans. <br /> All information required below is subject to verification and change by audit . <br /> Premium Basis Rate Per <br /> Code Total Estimated $ 100 of Estimated <br /> Classification No . Annual Remuneration Remuneration Annual Premium <br /> See Item 4 . Extension WC 00 00 01A For Rating & Assessments <br /> Total Estimated Standard Annual Premium 5O a 851 <br /> Expense Constant $ 200 <br /> Minimum Premium , 000 Deposit Premium 48 , 920 <br /> Premium Adjustment Penod : .Anna � a 1 .______,.y_... Countersigned by: <br /> Servicing and Issuing Office : Method I, C Omaha NF 68154 Date Produced : <br /> Copyright 1987 National Council on Compensation Insurance, <br /> I <br /> I <br /> k <br />