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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 89 06 00 B <br />(Ed. 7-01) <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br /> <br />(The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br />This endorsement, effective <br />Policy No. <br />Endorsement No.Issued to <br />Premium <br />By: <br />Carrier Code <br />(Ed. 7-01) <br />Authorized Representative <br />Countersigned at on <br />at 12:01 AM standard time, forms a part of <br />Of the <br />WC 89 06 00 B <br />. <br />Copyright 2001 National Council on Compensation Insurance, Inc. <br />*Item 4. Change To: <br />Classifications Code <br />No. <br />Premium Basis <br />Total Estimated <br />Annual <br />Remuneration <br />Rate Per $100 <br />of <br />Remuneration <br />Estimated <br />Annual Premium <br />Total Estimated Annual Premium $ <br />Minimum Premium $Deposit Premium $ <br />All other terms and conditions of this policy remain unchanged. <br /> <br />POLICY INFORMATION PAGE ENDORSEMENT <br />The following item(s) <br />[ ]Insured's Name (WC 89 06 01)[ ]Item 3.B. Limits (WC 89 06 12) <br />[ ]Policy Number (WC 89 06 02)[ ]Item 3.C. States (WC 89 06 13) <br />[ ]Effective Date (WC 89 06 03)[ ]Item 3.D. Endorsement Numbers (WC 89 06 14) <br />[ ]Expiration Date (WC 89 06 04)[ ]Item 4.* Class, Rate, Other (WC 89 04 15) <br />[ ]Insured's Mailing Address (WC 89 06 05)[ ]Interim Adjustment of Premium (WC 89 04 16) <br />[ ]Experience Modification (WC 89 04 06)[ ]Carrier Servicing Office (WC 89 06 17) <br />[ ]Producer's Name (WC 89 06 07)[ ]Interstate/Intrastate Risk ID Number (WC 89 06 18) <br />[ ]Change in Workplace of Insured (WC 89 06 08)[ ]Carrier Number (WC 89 06 19) <br />[ ]Insured's Legal Status (WC 89 06 10)[ ]Issuing Agency/Producer Office Address <br />[ ]Item 3.A. States (WC 89 06 11)(WC 89 06 25) <br />is changed to read: <br />For your protection California law requires the following to appear on this form: <br />Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make <br />a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. <br />PER AGENT REQUEST, ISSUED BLANKET WAIVER. <br />1,078 <br />500 135.80 <br />X <br />04/01/2025 <br />EIG 5927483 00 <br />001PROGRESSIVE SOLUTIONS INC <br /> $1,078 <br />EMPLOYERS PREFERRED INS. CO. <br />00920 <br />Docusign Envelope ID: 2EA41CCF-A2B2-47D6-84CA-2A61682545FC