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Policy PeriodPolicy Number From To <br />Transaction <br />1. Named Insured and Address Agent <br />Telephone: <br />Customer #Carrier #FEIN #Risk ID #Entity of Insured <br />Additional Locations: <br />2.The Policy Period is from to 12:01 a.m. Standard Time at the Insured's mailing address. <br />3.A.Workers Compensation Insurance: Part ONE of the policy applies to the Workers Compensation Law of the states <br />listed here: <br />B.Employers Liability Insurance: Part TWO of the policy applies to work in each state listed in Item 3A. <br />The limits of our liability under Part TWO are: <br />Bodily Injury by Accident $each accident <br />Bodily Injury by Disease $policy limit <br />Bodily Injury by Disease $each employee <br />C.Other States Insurance: Part THREE of the policy applies to the states, if any, listed here: <br />D.This policy includes these endorsements and schedules:See attached schedule. <br />4.The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans. <br />All information required below is subject to verification and change by audit. <br />SEE EXTENSION OF INFORMATION PAGE <br />Minimum Premium <br />Assessments and Taxes <br />This is a Three Year Fixed Rate Policy <br />Premium Adjustment Period:Annual;Semiannual;Quarterly;Monthly <br />Countersigned this Day of , <br />Authorized RepresentativeIssued Date: <br />Issuing Office <br />$ <br />$ <br />$Total Estimated AnnualPremium <br />Insured as stated herein 12:01 A.M. Standard Time at the address of the <br />$ <br />$ <br />Expense Constant <br />Premium Discount <br />NCCI Carrier #WCIRB CARRIER#PRIOR POLICY NUMBER00920 <br />Workers' Compensation and Employers Liability <br />Insurance Policy <br />EIG 5927483 00 04/01/2025 04/01/2026 <br />AMENDED DECLARATIONS Effective: 04/01/2025 <br />PROGRESSIVE SOLUTIONS INC <br />525 W WHITTIER BLVD <br />LA HABRA CA 90631 <br />0033005ADP - PITTSBURGH - SBS <br />EL PASO SALES <br />1 ADP BLVD M/S 625 <br />ROSELAND, NJ 07068 <br />8005247024 <br />330113562 CORPORATION <br />04/01/2025 04/01/2026 <br />CA, TN, WV <br /> 1,000,000 <br /> 1,000,000 <br /> 1,000,000 <br />All states except ND, OH, WA, WY and states listed in item 3.A. <br /> 500 160 <br />X <br />06/10/2025 <br /> 1,078 <br />P.O. BOX 539003 <br />HENDERSON, NV 89053-9003 <br />EMPLOYERS PREFERRED INS. CO. <br />EMPLOYERS PREFERRED INS. CO. <br />A Stock Company <br />31283 <br />NEW31283 <br />WC990630 (5/98 Ed.) <br />INSURED COPY06/10/2025Issued Date <br />Page 1 of 6 <br />Docusign Envelope ID: 2EA41CCF-A2B2-47D6-84CA-2A61682545FC