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1C213I11m INSURED'S COMFY <br />AML <br />THIS ENDORSEMENT IS HEREBY MADE A PART OF-111FOLILY <br />ISSUED TO; <br />INSURED'S NAME <br />POLICY NUMBER <br />KEY <br />NAME <br />SERV. <br />OIY. <br />DIY <br />PRODUCER <br />K `M SCRIVNER INC <br />IRB 957$891_ <br />lKMSCRj] <br />7S <br />IQS. <br />�QSS6 <br />PRODUCER FRANK B HALT C CO OF' <br />CALIFORNIA <br />WORKERS' COMPENSATION <br />5260 N PALM 10400 ` <br />AN <br />FRESNO CA: <br />93704 <br />EMPLOYER$' LIAPILITY,. <br />EN�QR$EIENT. <br />Induptria1 InOemnity <br />a Crum and Forster organization <br />INSURED K M SCRIVNER INC <br />DBA SCRIVNERS <br />SCRIVNER.ENVIRQNMENTAL. <br />SERVICES: <br />P 0 BOX 1075 <br />POS t.GX'PERIO� <br />CO.ALINGA9'CA 93210 <br />011D1/ TP'i! ,3,,/, 9?. <br />IT IS AGREED THAT THE POLICY DECLARATIONS ARE HEREBY AMENDED AS INDICATED BELOW: <br />EXPERIENCE <br />MOOIFTC TJON ENDORSEMENT.,` <br />THE EXPERIENCE 'MODIFICATION <br />SHOWN SHALL: O,E APPLIED TO THE PR h#IUb4 Q <br />FOR THE " STATE' INDICATED AT <br />MAN4JALR►TES,`` <br />"'P, <br />� <br />STATE <br />M0OIF�CATION` <br />EFFETIXE ;QTE <br />CALIFORNIA <br />0�1? <br />_ ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED.. <br />ENDORSEMENT NO.: COMPANY: <br />p� <br />INDUSTRIAL" INDEMNITY <br />CO® " <br />EFFECTIVE DATE:01 /01/92 ISSUED: <br />02/06/92, COUNTERSIGNED BY: <br />e <br />DI, <br />1C213I11m INSURED'S COMFY <br />