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C000001A <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INS <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. Policy No . SAMTWC 0 0 7 0 3 0 0 <br /> George Petersen Insurance <br /> Agency , Inc . 000663 Renewal of: NEW <br /> 175 W College Ave Individual Partnership <br /> Santa Rosa CA 95101 <br /> X Corporation or <br /> 1 . The Insured : service Station systems , Inc . Federal Employers I . D .# See Schedule <br /> NEI ww� <br /> Inter/Intrastate Risk I . D .# g 513 0 OR <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 $ 1 , 0 0 0 A 0600 each accident <br /> Bodily Injury by Disease $ 7 0 0 0 IF 0 0 0 _ policy limit <br /> Bodily Injury by Disease $ 1x 000000 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 50 857 <br /> Expense Constant $ 200 <br /> Minimum Premium n n n Deposit Premium 48 , 920 <br /> Premium Adjustment Period : Annua 1 Countersigned by: <br /> Servicing and Issuing Office : Method T 7 , C Omaha N > 6 £i 9 Date Produced : 06 / 031A I <br /> Copyright 1987 National Council on Compensation Insurance, <br />