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WORKERS COP <br />THIS FORMS A PART OF <br />POLICY NO. 92 -GP -Y170-9 <br />NAMED INSURED AND MAIL <br />BEYMER, STEVEN F' <br />DBA BEYMER WELL <br />PO BOX 1032 <br />COLUSA CA 9593; <br />NSATION AND EMPLOYERS LIABIL,TY POLICY <br />NFORMATION PAGE ENDORSEMENT <br />PAGE 01 <br />COVERAGE IS PROVIDED BY 23-0139-FA2F <br />STATE FARM FIRE AND CASUAITY COMPANY <br />PO Box 853925, Richardson TX 75085-3925 <br />G ADDRESS INTRASTATE TISK ID NO. 006187287 <br />EBBIE FEIN 562028'62 <br />PUMP <br />032 <br />DUE TO AN AI D I T <br />THE EFFECTIVE DATE IS 8/01/2020 <br />THE EXPIRATION DATE I 8/01/2021 <br />POLICY CODE NOS., CLAS- FICATIONS, PREMIUM BASIS, RA -TES AND ESTIMATED <br />PREMIUMS ARE AMENDED i. FOLLOWS: <br />------------------ <br />THE PREMIUM FOR THIS F <br />RULES, CLASSIFICATIONS <br />REQUIRED BELOW IS SUBt <br />-------------------------- <br />CODE NOS. AND <br />CLASSIFICATIONS <br />-------------------------- <br />6204 <br />DRILLING - NOC - NOT GEOTF <br />OR GAS PRODUCING, MINING C <br />NPD <br />COMPANY SURCHARGE FOR INCF <br />EMPLOYERS LIABILITY LIMIT <br />PREMIUM DISCOUNT <br />TERRORISM 9740 <br />MINIMUM PREMIUM $1000 CAI_ <br />---------------------------- ---- ---- <br />ICY WILL BE DETERMINED BY OUI; MANUALS OF <br />RATES AND RATING PLANS. ALL ]HFORMATION <br />T TO VERIFICATION AND CHANGE BY AUDIT <br />-------------------------------------------------- <br />PREMIUM <br />------------------------------------- ---I---------------I---------------- <br />M�ESTIMATED <br />NUESTIMATED <br />ATIERA-5REMIUM-- <br />MAL <br />NUL <br />------------ MA- -ION-----OI 120,526 11.09 13,366 <br />RYNG <br />SED <br />120,526 .03 <br />RNIA TOTAL ESTIMATED ANNI PREMIUM $ <br />STATE FRAUL URCHARGE $ <br />SEE SURCHARGE OVERFLOW PA,E <br />ALL OTHER TERMS AND CONDII NS OF THIS POLICY REMAIN UNCIANGED. <br />PREPARED 09/08/2020 <br />WC 99 00 02 04-84 COUNTERSIGNED <br />361 <br />-1,047 <br />36 <br />12,716 <br />43.00 <br />