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— WORKERS' COMPENS o BION AND EMPLOYERS LIABILITY INSURANCE POLICY <br /> `' INFORMATION PAUL FORM NUMBER: WC 00 OD o1 <br /> 0 FREMONT INDEMNITY COMPANY COMSTOCK INSURANCE COMPANY <br /> NEW POLICY NO: CW86-394780-01 <br /> PARTICIPATING <br /> 1 . THE INSURED AND MA1LIN6 ADDRESS: <br /> ASSEM14LY OF GOV <br /> P. U. bOX 38(- ENTITY: NON PROFIT CORP <br /> ESCALON CA 95320 <br /> bUREAU: <br /> OTHER WURKPLACcS NOT SHOWN ABOVE : <br /> 1920 CALIFORNIA STREET OFFICE : FRESNO <br /> ESLALON CA 95320 <br /> PRODUCER : AVERY—HAMML.R INSURANCE ASSOCIATES9 INC PRODUCER CODE: 3227/100 <br /> AGENCY BILL <br /> 2. POLICY PI.RIUD: FROM C5/01/66 TO 05/61/87 <br /> 12 :01 A.M. STANDARD TIME AT THE INSURaU*S MAILING ADDRESS. <br /> COVERAGE: <br /> A. WORKERS' LOMPENSATICkl INSURANCE : PART ONE OF THE POLICY APPLIES TO THE <br /> WORKERS' COMPENSATION LAWS OF THE STATES LISTED HERE: CALIFORNIA <br /> B. EMPLOYERS' LIABILITY INSURANCE- : PART TWO OF THE POLICY APPLIES TO WORK <br /> IN EACh STATE LISTED IN ITEM 3.A. THE LIMITS OF OUR LIABILITY UNDER <br /> PART TWO ARE: <br /> BODILY INJURY BY ACCIDENT: s100,00D EACH ACCIDENT <br /> BODILY INJURY BY DISEASE: 5100,000 EACH EMPLOYEE <br /> E BODILY INJURY BY DISEASE: s5009000 POLICY LIMIT <br /> 0 <br /> q C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO ALL THE <br /> `) STATES, IF ANY* LISTED HERE: NONE <br /> m <br /> c D. THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES: SCHEDULE: A <br /> ENDORStMENTS: Ci1.WC990601r 02.WC990301t 03.GOUN13189 04.WC99C302s <br /> 0 <br /> � :05.NC2ti_C4Ct <br /> 4. THE PREMIUM FOR THIS _POLICY WILL BE DETERMINED by OUR MANUALS OF RULESP <br /> CLASS IFICATIUNSv RATES AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS <br /> SUBJECT TO VERIFICATION AND CHANGE by AUDIT. <br /> O <br /> E PREMIUM BASIS: PREMIUM BASIS = TOTAL ESTIMATED ANNUAL REMUNERATION. <br /> 0 RATE = RATE PER $100 OF REMUNERATION. EAP = ESTIMATED ANNUAL PREMIUM. <br /> x <br /> PREMIUM <br /> ST. LODt CLASSIFICATION BASIS RATE EAP <br /> SEE tX1ENSION SLHEDULE A <br /> A NON REFUNOA3LE LICA ASSESSMENT OF $2 .U0 IS INCLUDED IN THE DEPOSIT. <br /> MINIMUM DEPOSIT L'CPOSIT TKANSFLR ADDITIONAL TOTAL ESTIMATED <br /> PREMIUM PREMIUM FROM DEPOSIT DUE ANNUAL PREMIUM <br /> ----- ----- ------------ --------- ------- <br /> $ It-toi $19579 SG si s19577 <br /> PAYROLL Ki:PURIING AND PRLMIUM ADJUSTMENT PERIUU : / <br /> INSTALLM:NT tILL1NG: y� <br /> PAYKULL REPOKTING FKtI,tUENCY: ANNUAL <br /> 4V <br /> COUNTERS16Nt :r Al LOS ANLi-LES9 CALIFOhNIA ON Q6-13—&6 BY: EDWARD J. LIEBER,SECRETARV <br /> INSURED <br />