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WORKERS CC ENSATION AND EMPLOYERS LIABi. TY POLICY <br />SUR( RGE OVERFLOW PAGE <br />GE NO : 01 <br />THIS FORMS A PART OF COVERAGE IS PROVIDE BY <br />POLICY NO. 92 -GP -Y170-9 STATE FARM FIRE AND CASUAL COMPANY <br />PO Box 853925, Richardson X 75085-3925 <br />NAMED INSURED AND MAIL G ADDRESS <br />BEYMER, STEVEN f EBBIE <br />DBA BEYMER WELL PUMP <br />PO BOX 1032 <br />COLUSA CA 9593 032 <br />INTRASTATE DISK ID NO. 006187287 <br />FEIN 562028962 <br />DUE TO AN IT <br />STATE SESSMENT $ <br />LBR ENFMT IOMPL ASMT $ <br />OCC SAFETY HLTH FUND $ <br />SUB INJ BENEFITS ASMT $ <br />UNIN EM BEIFFIT ASMT $ <br />PREPARED 09/08/2020 WC9900( ED 3-11) <br />217.00 <br />48.00 <br />50.00 <br />61 .00 <br />16.00 <br />