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COI - 6th Street Studios & Art Center - Certificate No. N/A | Start Date: 2024-02-08 | End Date: 2025-02-08DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 POLICY NUMBER: CNP-7013111909 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CG 20 26 11 85 Copyright, Insurance Services Office, Inc., 1984 Page 1 of 1 oo ADDITIONAL INSURED – DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule as an insured but only with respect to liability arising out of your operations or premises owned by or rented to you. City of Gilroy, it's officers, official and employees. 7351 Rosanna Street Gilroy, CA 95020 Service Agreement: Fire Department Personnel Testing City of Gilroy, it's officers, officials and employees as as additional insured, per the attachment endorsement. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 PAY00014 THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 July 6, 2022 6TH STREET STUDIOS 64 W 6TH ST GILROY CA 95020 Policy Information: Policy Number:76 WEG AS9WFU Contact Us Visit https://business.thehartford.com 24/7 access to pay bills, view policy documents, get your certificate of insurance and more. Need Help?Start a live chat online or call us at (877) 287-1312.We’re here weekdays from 8:00 AM to 8:00 PM ET Welcome to The Hartford! Dear Paychex Client, In affiliation with Paychex Insurance Agency,Inc.,we would like to thank you for choosing The Hartford for your business insurance and we would like you to know that we are extremely pleased to have the opportunity to serve you. We want to provide some telephone numbers and other information in case you have questions about your insurance or if you simply have comments or feedback for us.Whatever insurance services you may require,a professional staff representative will be happy to assist you. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Paychex New Business Welcome Letter Company & Agency Sold Business (Continued) PAY00014 Telephone Numbers for Questions/Comments/Feedback Paychex Insurance Agency, Inc. -Workers Compensation Payment Service billing inquiries The Hartford - Coverage questions, changes/endorsement to your current policy, issuance of certificate of insurance Phone:1 (877) 266-6850 Phone:1 (877) 287-1312 Fax:1 (800) 500-6770 Fax:1 (888) 443-6112 Monday-Friday, 8:30 AM – 8:00 PM EST Monday-Friday, 8:00 AM – 8:00 PM EST The Hartford - Quotes for additional lines of insurance The Hartford - Direct Bill Inquiries Phone:1 (800) 464-0923 Phone:1 (866) 467-8730 Fax:1 (877) 287-1313 Monday-Friday, 8:00 AM – 8:00 PM EST Monday-Friday, 8:00 AM – 8:00 PM EST To Report a Claim or Loss, Call (800) 327-3636. Representatives are available 24 hours a day, 365 days a year. We appreciate your business and look forward to servicing your commercial insurance needs. Sincerely, Your Hartford Service Team Please keep a copy of this letter with your Hartford Insurance Policy for future reference. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form 97485 18th Rev.Printed in U.S.A.Page 1 of 4 Process Date:07/06/22 Policy Expiration Date:06/25/23 Policy Number 76 WEG AS9WFU Policy Effective Date 06/25/22 6th Street Studios 64 W 6TH ST GILROY CA 95020 Dear Hartford Insured, Re: An Important Message to Workers Compensation Policyholders The control of workplace accidents and injuries should be among the highest priorities of your firm.Each accident wastes precious human and financial resources,and introduces inefficiencies into your operations.From a practical standpoint, the control of accidents, and their inevitable costs, simply makes good business sense. An effective risk engineering program can save you money and aggravation,can positively impact your loss experience (and thus your premium), and most importantly, can help you maintain solid control of your operations. As a service to you,our valued customer,the Risk Engineering Department of The Hartford in cooperation with your independent agent,can assist you in establishing risk engineering strategies.If you would like assistance, please complete and return to us the reply portion of this brochure, or contact your independent agent. Services Available The following is a description of some of the services that we provide.The types of services that may be appropriate for your business depend upon the nature and size of your operations and the specific risk engineering services you have requested.The cost of risk engineering services may or may not be a part of your insurance premium.This depends on the extent of the requested services,agreements stated in your insurance policy and program,and statutory regulations that may require us to provide risk engineering services. 1)Reference Materials –Information about risk engineering topics that can be provided or made available to you to help you to enhance your risk engineering program. 2)Telephone Consultation –We can hold a teleconference with you to help you to evaluate your risk engineering program,identify areas for improvement,and recommend ways to implement such improvements. 3)Onsite Consultation –This consists of visiting your premises and helping you to assess and remedy your risk engineering needs onsite.This level of service is usually only appropriate for larger,higher hazard operations.The following are examples of some of the services that could be provided onsite: o A review of your safety program to determine its adequacy and recommend modifications to that plan where needed. o Specific hazard evaluations, including ergonomics, industrial hygiene or material handling. o An initial survey and evaluation to address potential safety and health hazards. o Consultation to help management establish a comprehensive loss prevention Program. o Periodic summaries of accidents and analysis of causes. o Follow-up visits to check on progress and to provide continuing assistance when required. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form 97485 18th Rev.Printed in U.S.A.Page 2 of 4 A Word About OSHA The Occupational Safety and Health Act of 1970 and similarly approved State Plans require employers to provide their employees with safe and healthful places to work.The Occupational Safety and Health Administration (OSHA)of the U.S.Department of Labor and similar State agencies enforce the regulations and apply penalties (civil and criminal) for non-compliance. New standards have been developed,and through application and interpretation,standards change.You should make yourself aware of the standards that are applicable to your operations,and assure yourself that reasonable efforts are made to be in compliance.Copies of the standards are available through most libraries,or can be obtained through OSHA or the U.S. Government Printing Office. You should know that neither The Hartford,nor any other party,can fulfill your obligations under the Law. Questions related to your legal obligations should be referred to your legal counsel. Some Safety Reminders from The Hartford: Have you considered: o The need to formalize your safety efforts to assure compliance and document your efforts? o The need to acquire Material Safety Data Sheets on all hazardous materials and the need for training on appropriate safety measures for your employees? o Requirements for record keeping of injuries, illnesses, and exposure to hazardous substances? o Assessing each job task to determine hazards and needed controls? o Measuring each exposure to hazardous substances to determine the need for control or personal protective equipment? o What mechanisms are in place to periodically verify that exposure controls (guards,ventilation systems, etc.) are still in place and working? o What specific training your employees and your supervisors need to avoid hazards in the workplace? o What specific OSHA standards apply to your business? o What mechanism exists to promptly investigate all accidents and ‘near-misses’to limit the chance of another occurrence? o The financial impact an injury or illness has on your business? o What resources are available to you to help prevent accidents and illnesses? Thank you for your business. Sincerely, The Hartford's Risk Engineering Department DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form 97485 18th Rev.Printed in U.S.A.Page 3 of 4 THIS BROCHURE IS PROVIDED FOR INFORMATIONAL PURPOSES ONLY.IT IS NOT INTENDED TO BE A SUBSTITUTE FOR A COMPLETE ON-SITE SAFETY INSPECTION CONDUCTED BY A QUALIFIED RISK ENGINEERING SPECIALIST.READERS ARE ENCOURAGED TO HAVE SUCH AN INSPECTION CONDUCTED BOTH TO PROMOTE WORKPLACE SAFETY AND TO COMPLY WITH APPLICABLE LAW. FOR ADDITIONAL INFORMATION OR ASSISTANCE,EITHER TELEPHONE OR MAIL THIS FORM TO YOUR HARTFORD AGENT OR NEAREST OFFICE OF THE HARTFORD NOTICE TO ARKANSAS POLICYHOLDERS The Hartford is required by law to provide its policyholders with certain accident prevention services at no additional cost as required by ARK.Code Ann.§11-9-409(D)and Rule 32.If you would like more information,call The Hartford’s Risk Engineering Department,One Hartford Plaza,COG1,Hartford,CT 06155 at 1-866-586-0467. If you have any questions about this requirement,call the Health and Safety Division,Arkansas Workers’ Compensation Commission at 1-800-622-4472. NOTICE TO CALIFORNIA POLICYHOLDERS The Hartford is required by law to provide its policyholders with certain occupational safety and health risk engineering consultation services as required by the California Labor Code,§6354.5,at no additional charge.If you would like more information call The Hartford’s Risk Engineering Department at 1-866-586-0467 for occupational safety and health risk engineering consultation services. California Workers Compensation insurance policyholders may register comments about the insurer’s risk engineering consultation service by writing to: State of California Department of Industrial Relations Division of Occupational Safety and Health P.O. Box 420603 San Francisco, California 94142 NOTICE TO PENNSYLVANIA POLICYHOLDERS The Hartford maintains and provides accident and illness prevention services as required by the nature of the policyholder's business or its operation,in accordance with the Pennsylvania Workers'Compensation Act.For more information about these services contact your Hartford Agent or nearest office of The Hartford. NOTICE TO TEXAS POLICYHOLDERS Pursuant to Texas Labor Code §411.066,The Hartford is required to notify its policyholders that accident prevention services are available from The Hartford at no additional charge.These services may include surveys, recommendations,training programs,consultations,analyses of accident causes,industrial hygiene and industrial health services. The Hartford is also required to provide return-to-work coordination services as required by Texas Labor Code §413.021 and to notify you of the availability of the return-to-work reimbursement program for employers under Texas Labor Code §413.022. If you would like more information,contact The Hartford at 1-866-586-0467 and email contactriskengineering@thehartford.com for accident prevention services or 1-877-952-9222 and email CentralClaimCenter.WCEDM@thehartford.com for return-to-work coordination services. For information about these requirements call the Texas Department of Insurance,Division of Workers’ Compensation (TDI-DWC)at 1-800-687-7080 or for information about the return-to-work reimbursement program for employers call the TDI-DWC at 1-512-804-5000. If The Hartford fails to respond to your request for accident prevention services or return-to-work coordination services,you may file a complaint with the TDI-DWC in writing at http://www.tdi.texas.gov or by mail to Texas Department of Insurance, Division of Workers’ Compensation, P.O. Box 12050, Austin, Texas 78711. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form 97485 18th Rev.Printed in U.S.A.Page 4 of 4 Request for Technical Resources To The Hartford's Risk Engineering Department: Yes - I am interested in obtaining information concerning: General Topics Business Continuity Construction Accident Analysis Business Travel Safety Construction Site Consultation Accident Investigations Contingency Planning Overview Construction Equipment Hazards Establishing a Risk Engineering Program Emergency/Disaster Response Hazard Communication Hazard Recognition Emergency Evacuation Drills Ladders & Scaffolds Safety Committees Emergency Preparedness Planning Trenching & Evacuation Fall Protection Ergonomics Industrial Hygiene Property Back Injury Prevention Hazard Communication Automatic Sprinkler System Computer Workstation Industrial Hygiene (general)Flammable Liquids Cumulative Trauma Disorders Indoor Air Quality Fire Prevention and Protection Ergo Train-the-Trainer Noise Exposures Fire Drill and Evacuation Telecommuting Respiratory Protection Hot Work Permit Program Transportation Workers' Compensation Other Topics 3-D Driver Training Bloodborne Pathogens Business Risk Management Driving Defensively Drug Screening General Liability Investigations Fleet Newsletter Machine Safeguarding Product Liability Programs Guide to Successful Driver Mgmt Return to Work Programs Safety Training School Bus Driving Tips Slip and Falls Security/Terrorism Name Company Policy # Address City & State Zip Code Email Address:Telephone For more information on the above, you can visit our website at https://www.thehartford.com/riskengineering Or you may forward your request to: Fax line: 1-860-723-4459 Or mail to: The Hartford Financial Services Group Risk Engineering Department One Hartford Plaza, COG1 Hartford, CT 06155 DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form WC 99 00 02 (03/14)Page 1 of 1 Workers’ Compensation and Employers’ Liability Business Insurance Policy DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 (Policy Provisions:WC000000C) INFORMATION PAGE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY Form WC 00 00 01 A (1)Printed in U.S.A.Page 1 (Continued on next page) Process Date:07/06/22 Policy Expiration Date:06/25/23 INSURER:Sentinel Insurance Company Ltd. ONE HARTFORD PLAZA HARTFORD CT 06155 NCCI Company Number:13161 Company Code:A Suffix LARS RENEWAL POLICY NUMBER:76 WEG AS9WFU Previous Policy Number:New 1.Named Insured and Mailing Address: (No., Street, Town, State, Zip Code) 6TH STREET STUDIOS 64 W 6TH ST GILROY CA 95020 FEIN Number:85-4209688 State Identification Number(s): The Named Insured is:Association Business of Named Insured:Fine Arts Schools Other workplaces not shown above:64 W 6TH ST GILROY CA 95020 2.Policy Period:From 06/25/22 To 06/25/23 ANNUAL 12:01 a.m., Standard time at the insured's mailing address. Producer’s Name:PAYCHEX INSURANCE AGENCY INC 225 KENNETH DR STE 110 ROCHESTER NY 14623 Producer’s Code:76210757 Issuing Office:THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 (877) 287-1312 Total Estimated Annual Premium:$482 Deposit Premium: Policy Minimum Premium:$450 CA Audit Period:ANNUAL Installment Term: The policy is not binding unless countersigned by our authorized representative. Countersigned by 07/06/22 Authorized Representative Date DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 INFORMATION PAGE (Continued)Policy Number:76 WEG AS9WFU Form WC 00 00 01 A (1)Printed in U.S.A.Page 2 Process Date:07/06/22 Policy Expiration Date:06/25/23 3.A. Workers Compensation Insurance:Part one of the policy applies to the Workers Compensation Law of the states listed here:CA B. Employers Liability Insurance:Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily injury by Accident $1,000,000 each accident Bodily injury by Disease $1,000,000 policy limit Bodily injury by Disease $1,000,000 each employee C. Other States Insurance:Part Three of the policy applies to the states, if any , listed here: ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WYOMING, U.S.TERRITORIES AND STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE. D. This policy includes these endorsements and schedule: SEE ENDORSEMENT-WC 99 03 68 4.The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.All information required below is subject to verification and change by audit. Classifications Code Number and Description Premium Basis Total Estimated Annual Remuneration Rates Per $100 of Remuneration Estimated Annual Premium Total Standard Premium $250 Expense Constant $200 Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement $5 Estimated Annual Premium (before Surcharges)$455 Total Estimated Surcharges $27 *See the attached Schedule(s) of Operations for Location and State Level Premium Information Total Estimated Annual Premium:$482 Deposit Premium: Policy Minimum Premium:$450 CA Interstate/Intrastate Identification Number:Refer to Schedule of Operations NAICS: 611610 Labor Contractors Policy Number:SIC:5231 DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form WC 99 03 68 Printed in U.S.A. Process Date:07/06/22 Policy Expiration Date:06/25/23 EXTENSION OF THE INFORMATION PAGE - ITEM 3.D - ENDORSEMENTS Policy Number:76 WEG AS9WFU Endorsement Number: Effective Date:06/25/22 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:6th Street Studios 64 W 6TH ST GILROY CA 95020 Item 3.D. of the Information Page is completed to include the following endorsements: G-4119-0 POLICYHOLDER NOTICE-PAYROLL BILLING PN049901I POLICYHOLDER NOTICE - YOUR RIGHT TO RATING AND DIVIDEND INFORMATION WC000000C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC000001A.1 INFORMATION PAGE WC000001A.2 INFORMATION PAGE WC000422C TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT WC040301BB POLICY AMENDATORY ENDORSEMENT - CALIFORNIA WC040303C OFFICERS AND DIRECTORS COVERAGE/EXCLUSION ENDORSEMENT - CALIFORNIA WC040360B EMPLOYERS LIABILITY COVERAGE AMENDATORY ENDORSEMENT - CALIFORNIA WC040421 OPTIONAL PREMIUM INCREASE ENDORSEMENT - CALIFORNIA WC040601B CALIFORNIA CANCELATION ENDORSEMENT WC550011D Employees Claim for Workers compensation Benefits WC880400I Notice to Employees - Injuries Caused By Work (TITLE IN SPANISH) WC880401I Notice to Employees - Injuries Caused By Work WC990001J Signature/Copyright WC990002 WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY BUSINESS INSURANCE POLICY WC990005 SCHEDULE OF OPERATIONS DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form WC 99 03 68 Printed in U.S.A. Process Date:07/06/22 Policy Expiration Date:06/25/23 EXTENSION OF THE INFORMATION PAGE - ITEM 3.D - ENDORSEMENTS Policy Number:76 WEG AS9WFU Endorsement Number: Effective Date:06/25/22 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:6th Street Studios 64 W 6TH ST GILROY CA 95020 Item 3.D. of the Information Page is completed to include the following endorsements: WC990188 COVID-19 REPORTING REQUIREMENT ENDORSEMENT - CALIFORNIA WC990368 EXTENSION OF THE INFORMATION PAGE - ITEM 3.D. - ENDORSEMENTS WC990375 CALIFORNIA INSTALLMENT FEE DISCLOSURE ENDORSEMENT WC990689 GOODS AND SERVICES ENDORSEMENT DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 SCHEDULE OF OPERATIONS This Schedule of Operations forms a part of the policy effective on the inception date of the policy unless another date is indicated below: INSURER:SENTINEL INSURANCE COMPANY LTD. Company Code:A Policy Number:76 WEG AS9WFU Schedule Number:01-04-01 Effective Date:06/25/22 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Location Address of operations covered by this schedule: 6th Street Studios 64 W 6TH ST GILROY CA 95020 NAICS: 611610 FEIN:85-4209688 SIC: 5231 NO. OF EMPL: 5 4.The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans.All information required below is subject to verification and change by audit. Classifications Code Number and Description Premium Basis Total Estimated Annual Remuneration Rates Per $100 of Remuneration Estimated Annual Premium Countersigned by Authorized Representative Form WC 99 00 05 (1) Printed in U.S.A. Process Date:07/06/22 Policy Expiration Date:06/25/23 8868 COLLEGES OR SCHOOLS - PRIVATE - NOT AUTOMOBILE SCHOOLS - PROFESSORS, TEACHERS, OR ACADEMIC PROFESSIONAL EMPLOYEES 25,000.00 1.370000 343 Total State Summary Total Class Premium 343 CA Territorial Differential 0.698000 -104 Minimum Premium Adjustment 11 Total Estimated Annual Standard Premium 250 Expense constant 200 Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement 25,000.00 0.020000 5 CA User Fund 1.927700 9 CA Fraud 0.485600 2 CA Uninsured Employers Benefit Trust Fund 0.145500 1 CA Subsequent Injuries Benefit Trust Fund Assessments 1.745100 8 CA Occupational Safety & Health Fund 0.917700 4 CA Labor Enforcement & Compliance Fund 0.710200 3 Total Estimated Annual Premium 482 DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form WC 66 01 56 B Printed in U.S.A. Process Date:07/06/22 Policy Expiration Date:06/25/23 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY QUICK REFERENCE Beginning Beginning on Page on Page INFORMATION PAGE PART TWO - Continued 1 G.Limits of Liability ..............................................4 General Section..............................................................1 H.Recovery From Others.....................................4 A.The Policy...............................................................1 I.Actions Against Us...........................................4 B.Who Is Insured.......................................................1 C.Workers Compensation Law..................................1 PART THREE - OTHER STATES INSURANCE 4 D.State.......................................................................1 A.How This Insurance Applies.............................4 E.Locations................................................................1 B.Notice...............................................................5 PART ONE - WORKERS COMPENSATION INSURANCE...1 PART FOUR - YOUR DUTIES IF INJURY OCCURS.....5 A.How This Insurance Applies...................................1 B.We Will Pay............................................................1 PART FIVE - PREMIUM...............................................5 C.We Will Defend.......................................................1 A.Our Manuals.....................................................5 D.We Will Also Pay....................................................1 B.Classifications..................................................5 E.Other Insurance......................................................2 C.Remuneration...................................................5 F.Payments You Must Make......................................2 D.Premium Payments..........................................5 G.Recovery From Others...........................................2 E.Final Premium..................................................5 H.Statutory Provisions................................................2 F.Records............................................................6 G.Audit.................................................................6 PART TWO - EMPLOYERS LIABILITY INSURANCE......2 A.How This Insurance Applies...................................2 PART SIX - CONDITIONS.......................................6 B.We will Pay.............................................................3 A.Inspection.........................................................6 C.Exclusions..............................................................3 B.Long Term Policy.............................................6 D.We Will Defend.......................................................3 C.Transfer of Your Rights and Duties..................6 E.We Will Also Pay....................................................4 D.Cancellation.....................................................6 F.Other Insurance......................................................4 E.Sole Representative.........................................6 IMPORTANT:This Quick Reference is not part of the Workers Compensation and Employers Liability Policy and does not provide coverage.Refer to the Workers Compensation and Employers Liability Policy itself for actual contractual provisions. PLEASE READ THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CAREFULLY. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form WC 00 00 00 C Printed in U.S.A.Page 1 of 6 Process Date: 07/06/22 Policy Expiration Date: 06/25/23 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows: GENERAL SECTION A.The Policy This policy includes at its effective date the Information Page and all endorsements and schedules listed there.It is a contract of insurance between you (the employer named in Item 1 of the Information Page)and us (the insurer named on the Information Page).The only agreements relating to this insurance are stated in this policy.The terms of this policy may not be changed or waived except by endorsement issued by us to be part of this policy. B.Who Is Insured You are insured if you are an employer named in Item 1 of the Information Page.If that employer is a partnership,and if you are one of its partners,you are insured,but only in your capacity as an employer of the partnership's employees. C.Workers Compensation Law Workers Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in Item 3.A.of the Information Page.It includes any amendments to that law which are in effect during the policy period.It does not include any federal workers or workmen's compensation law,any federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. D.State State means any state of the United States of America, and the District of Columbia. E.Locations This policy covers all of your workplaces listed in Items 1 or 4 of the Information Page;and it covers all other workplaces in Item 3.A.states unless you have other insurance or are self-insured for such workplaces. PART ONE - WORKERS COMPENSATION INSURANCE A.How This Insurance Applies This workers compensation insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1.Bodily injury by accident must occur during the policy period. 2.Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. B.We Will Pay We will pay promptly when due the benefits required of you by the workers compensation law. C.We Will Defend We have the right and duty to defend at our expense any claim,proceeding or suit against you for benefits payable by this insurance.We have the right to investigate and settle these claims,proceedings or suits. We have no duty to defend a claim,proceeding or suit that is not covered by this insurance. D.We Will Also Pay We will also pay these costs,in addition to other amounts payable under this insurance,as part of any claim, proceeding or suit we defend: 1.reasonable expenses incurred at our request,but not loss of earnings; DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form WC 00 00 00 C Printed in U.S.A.Page 2 of 6 2.premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amount payable under this insurance; 3.litigation costs taxed against you; 4.interest on a judgment as required by law until we offer the amount due under this insurance; and 5.expenses we incur. E.Other Insurance We will not pay more than our share of benefits and costs covered by this insurance and other insurance or self-insurance.Subject to any limits of liability that may apply,all shares will be equal until the loss is paid.If any insurance or self-insurance is exhausted, the shares of all remaining insurance will be equal until the loss is paid. F.Payments You Must Make You are responsible for any payments in excess of the benefits regularly provided by the workers compensation law including those required because: 1.of your serious and willful misconduct; 2.you knowingly employ an employee in violation of law; 3.you fail to comply with a health or safety law or regulation; or 4.you discharge,coerce or otherwise discriminate against any employee in violation of the workers compensation law. If we make any payments in excess of the benefits regularly provided by the workers compensation law on your behalf, you will reimburse us promptly. G.Recovery From Others We have your rights,and the rights of persons entitled to the benefits of this insurance,to recover our payments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. H.Statutory Provisions These statements apply where they are required by law. 1.As between an injured worker and us,we have notice of the injury when you have notice. 2.Your default or the bankruptcy or insolvency of you or your estate will not relieve us of our duties under this insurance after an injury occurs. 3.We are directly and primarily liable to any person entitled to the benefits payable by this insurance. Those persons may enforce our duties;so may an agency authorized by law.Enforcement may be against you and us. 4.Jurisdiction over you is jurisdiction over us for purposes of the workers compensation law.We are bound by decisions against you under that law,subject to the provisions of this policy that are not in conflict with that law. 5.This insurance conforms to the parts of the workers compensation law that apply to: a.benefits payable by this insurance; b.special taxes,payments into security or other special funds,and assessments payable by us under that law. 6.Terms of this insurance that conflict with the workers compensation law are changed by this statement to conform to that law. Nothing in these paragraphs relieves you of your duties under this policy. PART TWO - EMPLOYERS LIABILITY INSURANCE A.How This Insurance Applies This employers liability insurance applies to bodily injury by accident or bodily injury by disease.Bodily injury includes resulting death. 1.The bodily injury must arise out of and in the course of the injured employee's employment by you. 2.The employment must be necessary or incidental to your work in a state or territory listed in Item 3.A. of the Information Page. 3.Bodily injury by accident must occur during the policy period. 4.Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form WC 00 00 00 C Printed in U.S.A.Page 3 of 6 exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5.If you are sued,the original suit and any related legal actions for damages for bodily injury by accident or by disease must be brought in the United States of America,its territories or possessions, or Canada. B.We Will Pay We will pay all sums that you legally must pay as damages because of bodily injury to your employees, provided the bodily injury is covered by this Employers Liability Insurance. The damages we will pay,where recovery is permitted by law, include damages: 1.For which you are liable to a third party by reason of a claim or suit against you by that third party to recover the damages claimed against such third party as a result of injury to your employee; 2.For care and loss of services; and 3.For consequential bodily injury to a spouse,child, parent,brother or sister of the injured employee; provided that these damages are the direct consequence of bodily injury that arises out of and in the course of the injured employee's employment by you; and 4.Because of bodily injury to your employee that arises out of and in the course of employment, claimed against you in a capacity other than as employer. C.Exclusions This insurance does not cover: 1.Liability assumed under a contract.This exclusion does not apply to a warranty that your work will be done in a workmanlike manner; 2.Punitive or exemplary damages because of bodily injury to an employee employed in violation of law; 3.Bodily injury to an employee while employed in violation of law with your actual knowledge or the actual knowledge of any of your executive officers; 4.Any obligation imposed by a workers com- pensation,occupational disease,unemployment compensation,or disability benefits law,or any similar law; 5.Bodily injury intentionally caused or aggravated by you; 6.Bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America or Canada who is temporarily outside these countries; 7.Damages arising out of coercion,criticism, demotion,evaluation,reassignment,discipline, defamation,harassment,humiliation,dis- crimination against or termination of any employee,or any personnel practices,policies, acts or omissions; 8.Bodily injury to any person in work subject to the Longshore and Harbor Workers'Compensation Act (33 U.S.C.Sections 901 et seq.),the Noappropriated Fund Instrumentalities Act (5 U.S.C.Sections 8171 et seq.),the Outer Continental Shelf Lands Act (43 U.S.C.Sections 1331 et seq.),the Defense Base Act (42 U.S.C. Sections 1651-1654),the Federal Mine Safety and Health Act (30 U.S.C.Sections 801 et seq. and 901-944)any other federal workers or workmen's compensation law or other federal occupational disease law,or any amendments to these laws; 9.Bodily injury to any person in work subject to the Federal Employers'Liability Act (45 U.S.C. Sections 51 et seq.),any other federal laws obligating an employer to pay damages to an employee due to bodily injury arising out of or in the course of employment,or any amendments to those laws; 10.Bodily injury to a master or member of the crew of any vessel,and does not cover punitive damages related to your duty or obligation to provide transportation,wages,maintenance,and cure under any applicable maritime law; 11.Fines or penalties imposed for violation of federal or state law; and 12.Damages payable under the Migrant and Seasonal Agricultural Worker Protection Act (29 U.S.C.Sections 1801 et seq.)and under any other federal law awarding damages for violation of those laws or regulations issued thereunder, and any amendments to those laws. D.We Will Defend We have the right and duty to defend,at our expense, any claim,proceeding or suit against you for damages payable by this insurance.We have the right to investigate and settle these claims,proceedings and suits. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form WC 00 00 00 C Printed in U.S.A.Page 4 of 6 We have no duty to defend a claim,proceeding or suit that is not covered by this insurance.We have no duty to defend or continue defending after we have paid our applicable limit of liability under this insurance. E.We Will Also Pay We will also pay these costs,in addition to other amounts payable under this insurance,as part of any claim, proceeding or suit we defend: 1.Reasonable expenses incurred at our request,but not loss of earnings; 2.Premiums for bonds to release attachments and for appeal bonds in bond amounts up to the limit of our liability under this insurance; 3.Litigation costs taxed against you; 4.Interest on a judgment as required by law until we offer the amount due under this insurance; and 5.Expenses we incur. F.Other Insurance We will not pay more than our share of damages and costs covered by this insurance and other insurance or self-insurance.Subject to any limits of liability that apply,all shares will be equal until the loss is paid.If any insurance or self-insurance is exhausted,the shares of all remaining insurance and self-insurance will be equal until the loss is paid. G.Limits of Liability Our liability to pay for damages is limited.Our limits of liability are shown in Item 3.B.of the Information Page. They apply as explained below. 1.Bodily Injury by Accident.The limit shown for ''bodily injury by accident each accident''is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident. A disease is not bodily injury by accident unless it results directly from bodily injury by accident. 2.Bodily Injury by Disease.The limit shown for ''bodily injury by disease policy limit''is the most we will pay for all damages covered by this insurance and arising out of bodily injury by disease,regardless of the number of employees who sustain bodily injury by disease.The limit shown for ''bodily injury by disease each employee''is the most we will pay for all damages because of bodily injury by disease to any one employee. Bodily injury by disease does not include disease that results directly from a bodily injury by accident. 3.We will not pay any claims for damages after we have paid the applicable limit of our liability under this insurance. H.Recovery From Others We have your rights to recover our payment from anyone liable for an injury covered by this insurance. You will do everything necessary to protect those rights for us and to help us enforce them. I.Actions Against Us There will be no right of action against us under this insurance unless: 1.You have complied with all the terms of this policy; and 2.The amount you owe has been determined with our consent or by actual trial and final judgment. This insurance does not give anyone the right to add us as a defendant in an action against you to determine your liability.The bankruptcy or insolvency of you or your estate will not relieve us of our obligations under this Part. PART THREE - OTHER STATES INSURANCE A.How This Insurance Applies 1.This other states insurance applies only if one or more states are shown in Item 3.C.of the Information Page. 2.If you begin work in any one of those states after the effective date of this policy and are not insured or are not self-insured for such work,all provisions of the policy will apply as though that state were listed in Item 3.A. of the Information Page. 3.We will reimburse you for the benefits required by the workers compensation law of that state if we are not permitted to pay the benefits directly to persons entitled to them. 4.If you have work on the effective date of this policy in any state not listed in Item 3.A. of the DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form WC 00 00 00 C Printed in U.S.A.Page 5 of 6 Information Page,coverage will not be afforded for that state unless we are notified within thirty days. B.Notice Tell us at once if you begin work in any state listed in Item 3.C. of the Information Page. PART FOUR - YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered by this policy.Your other duties are listed here. 1.Provide for immediate medical and other services required by the workers compensation law. 2.Give us or our agent the names and addresses of the injured persons and of witnesses,and other information we may need. 3.Promptly give us all notices,demands and legal papers related to the injury,claim,proceeding or suit. 4.Cooperate with us and assist us,as we may request,in the investigation,settlement or defense of any claim, proceeding or suit. 5.Do nothing after an injury occurs that would interfere with our right to recover from others. 6.Do not voluntarily make payments,assume obligations or incur expenses,except at your own cost. PART FIVE - PREMIUM A.Our Manuals All premium for this policy will be determined by our manuals of rules,rates,rating plans and classifications.We may change our manuals and apply the changes to this policy if authorized by law or a governmental agency regulating this insurance. B.Classifications Item 4 of the Information Page shows the rate and premium basis for certain business or work classifications.These classifications were assigned based on an estimate of the exposures you would have during the policy period.If your actual exposures are not properly described by those classifications,we will assign proper classifications, rates and premium basis by endorsement to this policy. C.Remuneration Premium for each work classification is determined by multiplying a rate times a premium basis. Remuneration is the most common premium basis. This premium basis includes payroll and all other remuneration paid or payable during the policy period for the services of: 1.All your officers and employees engaged in work covered by this policy; and 2.all other persons engaged in work that could make us liable under Part One (Workers Compensation Insurance)of this policy.If you do not have payroll records for these persons,the contract price for their services and materials may be used as the premium basis.This paragraph 2 will not apply if you give us proof that the employers of these persons lawfully secured their workers compensation obligations. D.Premium Payments You will pay all premium when due.You will pay the premium even if part or all of a workers compensation law is not valid. E.Final Premium The premium shown on the Information Page, schedules,and endorsements is an estimate.The final premium will be determined after this policy ends by using the actual,not the estimated,premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy.If the final premium is more than the premium you paid to us,you must pay us the balance.If it is less,we will refund the balance to you.The final premium will not be less than the highest minimum premium for the classifications covered by this policy. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form WC 00 00 00 C Printed in U.S.A.Page 6 of 6 If this policy is cancelled,final premium will be determined in the following way unless our manuals provide otherwise: 1.If we cancel,final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. 2.If you cancel,final premium will be more than pro rata;it will be based on the time this policy was in force,and increased by our short rate cancellation table and procedure.Final premium will not be less than the minimum premium. F.Records You will keep records of information needed to compute premium.You will provide us with copies of those records when we ask for them. G.Audit You will let us examine and audit all your records that relate to this policy.These records include ledgers, journals,registers,vouchers,contracts,tax reports, payroll and disbursement records,and programs for storing and retrieving data.We may conduct the audits during regular business hours during the policy period and within three years after the policy period ends.Information developed by audit will be used to determine final premium.Insurance rate service organizations have the same rights we have under this provision. PART SIX - CONDITIONS A.Inspection We have the right,but are not obligated to inspect your workplaces at any time.Our inspections are not safety inspections.They relate only to the insurability of the workplaces and the premiums to be charged. We may give you reports on the conditions we find. We may also recommend changes.While they may help reduce losses,we do not undertake to perform the duty of any person to provide for the health or safety of your employees or the public.We do not warrant that your workplaces are safe or healthful or that they comply with laws,regulations,codes or standards.Insurance rate service organizations have the same rights we have under this provision. B.Long Term Policy If the policy period is longer than one year and sixteen days,all provisions of this policy will apply as though a new policy were issued on each annual anniversary that this policy is in force. C.Transfer of Your Rights and Duties Your rights or duties under this policy may not be transferred without our written consent. If you die and we receive notice within thirty days after your death,we will cover your legal representative as insured. D.Cancellation 1.You may cancel this policy.You must mail or deliver advance written notice to us stating when the cancellation is to take effect. 2.We may cancel this policy.We must mail or deliver to you not less than ten days advance written notice stating when the cancellation is to take effect.Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 3.The policy period will end on the day and hour stated in the cancellation notice. 4.Any of these provisions that conflict with a law that controls the cancellation of the insurance in this policy is changed by this statement to comply with that law. E.Sole Representative The insured first named in Item 1 of the Information Page will act on behalf of all insureds to change this policy,receive return premium,and give or receive notice of cancellation. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form PN 04 99 02 B (Ed. 5-02)Printed in U.S.A.Page 1 of 2 POLICYHOLDER NOTICE CALIFORNIA WORKERS' COMPENSATION INSURANCE RATING LAWS Pursuant to Section 11752.8 of the California Insurance Code,we are providing you with an explanation of the California workers' compensation rating laws. 1.We establish our own rates for workers’ compensation.Our rates,rating plans,and related information are filed with the insurance commissioner and are open for public inspection. 2.The insurance commissioner can disapprove our rates,rating plans,or classifications only if he or she has determined after public hearing that our rates might jeopardize our ability to pay claims or create a monopoly in the market.A monopoly is defined by law as a market where one insurer writes 20%or more of that part of the California workers' compensation insurance that is not written by the State Compensation Insurance Fund.If the insurance commissioner disapproves our rates, rating plans,or classifications,he or she may order an increase in the rates applicable to outstanding policies. 3.Rating organizations may develop pure premium rates that are subject to the insurance commissioner's approval.A pure premium rate reflects the anticipated cost and expenses of claims per $100 of payroll for a given classification.Pure premium rates are advisory only,as we are not required to use the pure premium rates developed by any rating organization in establishing our own rates. 4.We must adhere to a single,uniform experience rating plan.If you are eligible for experience rating under the plan, we will be required to adjust your premium to reflect your claim history.A better claim history generally results in a lower experience rating modification;more claims,or more expensive claims,generally result in a higher experience rating modification.The uniform experience rating plan, which is developed by the insurance rating organization designated by the insurance commissioner,is subject to approval by the insurance commissioner. 5.A standard classification system,developed by the insurance rating organization designated by the insurance commissioner,is subject to approval by the insurance commissioner.The standard classification system is a method of recognizing and separating policyholders into industry or occupational groups according to their similarities and/or differences.We can adopt and apply the standard classification system or develop and apply our own classification system,provided we can report the payroll,expenses,and other costs of claims in a way that is consistent with the uniform statistical plan or the standard classification system. 6.Our rates and classifications may not violate the Unruh Civil Rights Act or be unfairly discriminatory. 7.We will provide an appeal process for you to appeal the way we rate your insurance policy.The process requires us to respond to your written appeal within 30 days.If you are not satisfied with the result of your appeal,you may appeal our decision to the insurance commissioner. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form PN 04 99 02 B (Ed. 5-02)Printed in U.S.A.Page 2 of 2 CALIFORNIA WORKERS’ COMPENSATION INSURANCE NOTICE OF NONRENEWAL Section 11664 of the California Insurance Code requires us,in most instances,to provide you with a notice of nonrenewal.Except as specified in paragraphs 1 through 6 below,if we elect to nonrenew your policy,we are required to deliver or mail to you a written notice stating the reason or reasons for the nonrenewal of the policy.The notice is required to be sent to you no earlier than 120 days before the end of the policy period and no later than 30 days before the end of the policy period.If we fail to provide you the required notice,we are required to continue the coverage under the policy with no change in the premium rate until 60 days after we provide you with the required notice. We are not required to provide you with a notice of nonrenewal in any of the following situations: 1.Your policy was transferred or renewed without a change in its terms or conditions or the rate on which the premium is based to another insurer or other insurers who are members of the same insurance group as us. 2.The policy was extended for 90 days or less and the required notice was given prior to the extension. 3.You obtained replacement coverage or agreed,in writing,within 60 days of the termination of the policy, to obtain that coverage. 4.The policy is for a period of no more than 60 days and you were notified at the time of issuance that it may not be renewed. 5.You requested a change in the terms or conditions or risks covered by the policy within 60 days prior to the end of the policy period. 6.We made a written offer to you to renew the policy at a premium rate increase of less than 25 percent. (A)If the premium rate in your governing classification is to be increased 25 percent or greater and we intend to renew the policy,we shall provide a written notice of a renewal offer not less than 30 days prior to the policy renewal date.The governing classification shall be determined by the rules and regulations established in accordance with California Insurance Code 11750.3(c). (B)For purposes of this Notice,“premium rate” means the cost of insurance per unit of exposure prior to the application of individual risk variations based on loss or expense considerations such as scheduled rating and experience rating. This notice does not change the policy to which it is attached. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form G-4119-0 Printed in U.S.A. © 2017, The Hartford POLICY HOLDER NOTICE - PAYROLL BILLING Thank you for choosing The Hartford.Your policy is on our payroll billing method.The payroll billing method uses actual payrolls received throughout the policy period and a blended rate(s)to determine premiums due during the policy period. To learn more about how your premium is calculated on the payroll billing method please visit: https://www.thehartford.com/blended Below are the blended rate(s) being used for each state and classification code on your policy: State Class Code Blended Rate Effective 1: 64 W 6TH ST, GILROY, CA 8868 1.130000 06/25/2022 DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form PN 04 99 01 I (02/22)Printed in U.S.A.Page 1 of 3 Process Date: 07/06/22 Policy Expiration Date:06/25/23 POLICYHOLDER NOTICE YOUR RIGHT TO RATING AND DIVIDEND INFORMATION I.Information Available to You A.Information Available from Us -Sentinel Insurance Company Ltd. (1)General questions regarding your policy should be directed to your Hartford Agent or Sentinel Insurance Company Ltd. 3600 Wiseman Blvd San Antonio, TX 78251 Telephone:(877) 287-1312 agency.services@thehartford.com www.thehartford.com (2)Dividend Calculation.If this is a participating policy (a policy on which a dividend may be paid),upon payment or non-payment of a dividend,we shall provide a written explanation to you that sets forth the basis of the dividend calculation.The explanation will be in clear,understandable language and will express the dividend as a dollar amount and as a percentage of the earned premium for the policy year on which the dividend is calculated. (3)Claims Information.Pursuant to Sections 3761 and 3762 of the California Labor Code,you are entitled to receive information in our claim files that affects your premium.Copies of documents will be supplied at your expense during reasonable business hours. For claims covered under this policy,we will estimate the ultimate cost of unsettled claims for statistical purposes eighteen months after the policy becomes effective and will report those estimates to the Workers'Compensation Insurance Rating Bureau of California (WCIRB)no later than twenty months after the policy becomes effective.The cost of any settled claims will also be reported at that time.At twelve- month intervals thereafter,we will update and report to the WCIRB the estimated cost of any unsettled claims and the actual final cost of any claims settled in the interim.The amounts we report will be used by the WCIRB to compute your experience modification if you are eligible for experience rating. B.Information Available from the Workers' Compensation Insurance Rating Bureau of California (1)The WCIRB is a licensed rating organization and the California Insurance Commissioner's designated statistical agent.As such,the WCIRB is responsible for administering the California Workers' Compensation Uniform Statistical Reporting Plan—1995 (USRP)and the California Workers' Compensation Experience Rating Plan—1995 (ERP).WCIRB contact information is:WCIRB,1901 Harrison Street,17th Floor,Oakland,CA 94612,Attn:Customer Service;888.229.2472 (phone); 415.778.7272 (fax);and customerservice@wcirb.com (email).The regulations contained in the USRP and ERP are available for public viewing through the WCIRB's website at wcirb.com. (2)Policyholder Information.Pursuant to California Insurance Code (CIC)Section 11752.6,upon written request,you are entitled to information relating to loss experience,claims,classification assignments,and policy contracts as well as rating plans,rating systems,manual rules,or other information impacting your premium that is maintained in the records of the WCIRB.Complaints and Requests for Action requesting policyholder information should be forwarded to:WCIRB,1901 Harrison Street,17th Floor,Oakland,CA 94612,Attn:Custodian of Records.The Custodian of Records can be reached at 415.777.0777 (phone) and 415.778.7272 (fax). DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form PN 04 99 01 I (02/22)Printed in U.S.A.Page 2 of 3 (3)Experience Rating Form.Each experience rated risk may receive a single copy of its current Experience Rating Form/Worksheet free of charge by completing a Policyholder Experience Rating Worksheet Request Form on the WCIRB's website at wcirb.com/ratesheet.The Experience Rating Form/Worksheet will include a Loss-Free Rating,which is the experience modification that would have been calculated if $0 (zero)actual losses were incurred during the experience period.This hypothetical rating calculation is provided for informational purposes only. II.Dispute Process You may dispute our actions or the actions of the WCIRB pursuant to CIC Sections 11737 and 11753.1. A.Our Dispute Resolution Process. You may send us a written Complaint and Request for Action requesting that we reconsider a change in a classification assignment that results in an increased premium and/or requesting that we review the manner in which our rating system has been applied in connection with the insurance afforded or offered you.Written Complaints and Requests for Action should be forwarded to: Sentinel Insurance Company Ltd. One Pointe Drive, Suite 200, Brea, CA 92821; Telephone (800) 451-6944; Fax (860) 723-4289. After you send your Complaint and Request for Action,we have 30 days to send you a written notice indicating whether your written request will be reviewed.If we agree to review your request,we must conduct the review and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review.If we decline to review your request,if you are dissatisfied with the decision upon review,or if we fail to grant or reject your request or issue a decision upon review,you may appeal to the Insurance Commissioner as described in paragraph II.C., below. B.Disputing the Actions of the WCIRB.If you have been aggrieved by any decision,action,or omission to act of the WCIRB,you may request,in writing,that the WCIRB reconsider its decision,action,or omission to act. You may also request,in writing,that the WCIRB review the manner in which its rating system has been applied in connection with the insurance afforded or offered you.For requests related to classification disputes,the reporting of experience,or coverage issues,your initial request for review must be received by the WCIRB within 12 months after the expiration date of the policy to which the request for review pertains, except if the request involves the application of the Revision of Losses rule.For requests related to your experience modification,your initial request for review must be received by the WCIRB within 6 months after the issuance,or 12 months after the expiration date,of the experience modification to which the request for review pertains,whichever is later,except if the request for review involves the application of the Revision of Losses rule.If the request involves the Revision of Losses rule,the time to state your appeal may be longer. (See Section VI, Rule 7 of the ERP). You may commence the review process by sending the WCIRB a written Inquiry.Written Inquiries should be sent to:WCIRB,1901 Harrison Street,17th Floor,Oakland,CA 94612,Attn:Customer Service. Customer Service can be reached at 888.229.2472 (phone),415.778.7272 (fax)and customerservice@wcirb.com (email). If you are dissatisfied with the WCIRB's decision upon an Inquiry,or if the WCIRB fails to respond within 90 days after receipt of the Inquiry,you may pursue the subject of the Inquiry by sending the WCIRB a written Complaint and Request for Action.After you send your Complaint and Request for Action,the WCIRB has 30 days to send you written notice indicating whether your written request will be reviewed.If the WCIRB agrees to review your request,it must conduct the review and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review.If the WCIRB declines to review your request,if you are dissatisfied with the decision upon review,or if the WCIRB fails to grant or reject your request or issue a decision upon review,you may appeal to the Insurance Commissioner as described in paragraph II.C.,below.Written Complaints and Requests for Action should be forwarded to:WCIRB,1901 Harrison Street,17th Floor,Oakland,CA 94612,Attn:Complaints and Reconsideration.The WCIRB's contact information is 888.229.2472 (phone),415.371.5204 (fax)and customerservice@wcirb.com (email). DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form PN 04 99 01 I (02/22)Printed in U.S.A.Page 3 of 3 C.California Department of Insurance –Appeals to the Insurance Commissioner.After you follow the appropriate dispute resolution process described above,if (1)we or the WCIRB decline to review your request,(2)you are dissatisfied with the decision upon review,or (3)we or the WCIRB fail to grant or reject your request or issue a decision upon review,you may appeal to the Insurance Commissioner pursuant to CIC Sections 11737,11752.6,11753.1 and Title 10,California Code of Regulations,Section 2509.40 et seq. You must file your appeal within 30 days after we or the WCIRB send you the notice rejecting review of your Complaint and Request for Action or the decision upon your Complaint and Request for Action.If no written decision regarding your Complaint and Request for Action is sent,your appeal must be filed within 120 days after you sent your Complaint and Request for Action to us or to the WCIRB.The filing address for all appeals to the Insurance Commissioner is: Administrative Hearing Bureau California Department of Insurance 1901 Harrison Street, 3rd Floor Mailroom Oakland, CA 94612 415.538.4243 You have the right to a hearing before the Insurance Commissioner,and our action,or the action of the WCIRB, may be affirmed, modified or reversed. III.Resources Available to You in Obtaining Information and Pursuing Disputes A.Policyholder Ombudsman.Pursuant to California Insurance Code Section 11752.6,a policyholder ombudsman is available at the WCIRB to assist you in obtaining and evaluating the rating,policy,and claims information referenced in I.A.and I.B.,above.The ombudsman may advise you on any dispute with us,the WCIRB,or on an appeal to the Insurance Commissioner pursuant to Section 11737 of the Insurance Code. The address of the policyholder ombudsman is WCIRB,1901 Harrison Street,17th Floor,Oakland,CA 94612, Attn:Policyholder Ombudsman.The policyholder ombudsman can be reached at 415.778.7159 (phone), 415.371.5288 (fax) and ombudsman@wcirb.com (email). B.California Department of Insurance -Information and Assistance.Information and assistance on policy questions can be obtained from the Department of Insurance Consumer HOTLINE,800.927.HELP (4357)or insurance.ca.gov.For questions and correspondence regarding appeals to the Administrative Hearing Bureau, see the contact information in paragraph II.C. This notice does not change the policy to which it is attached. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 04 03 01 BB Printed in U.S.A.Page 1 of 2 Process Date:07/06/22 Policy Expiration Date:06/25/23 POLICY AMENDATORY ENDORSEMENT - CALIFORNIA Policy Number:76 WEG AS9WFU Endorsement Number: Effective Date:06/25/22 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:6th Street Studios 64 W 6TH ST GILROY CA 95020 It is agreed that,anything in the policy to the contrary notwithstanding,such insurance as is afforded by this policy by reason of the designation of California in Item 3 of the Information Page is subject to the following provisions: 1.Minors Illegally Employed -Not Insured.This policy does not cover liability for additional compensation imposed on you under Section 4557, Division IV,Labor Code of the State of California, by reason of injury to an employee under sixteen years of age and illegally employed at the time of injury. 2.Punitive or Exemplary Damages -Uninsurable. This policy does not cover punitive or exemplary damages where insurance of liability therefor is prohibited by law or contrary to public policy. 3.Increase in Indemnity Payment - Reimbursement.You are obligated to reimburse us for the amount of increase in indemnity payments made pursuant to Subdivision (d)of Section 4650 of the California Labor Code,if the late indemnity payment which gives rise to the increase in the amount of payment is due less than seven (7)days after we receive the completed claim form from you.You are obligated to reimburse us for any increase in indemnity payments not covered under this policy and will reimburse us for any increase in indemnity payment not covered under the policy when the aggregate total amount of the reimbursement payments paid in a policy year exceeds one hundred dollars ($100). If we notify you in writing,within 30 days of the payment,that you are obligated to reimburse us,we will bill you for the amount of increase in indemnity payment and collect it no later than the final audit. You will have 60 days,following notice of the obligation to reimburse,to appeal the decision of the insurer to the Department of Insurance. 4.Application of Policy.Part One,"Workers Compensation Insurance",A,"How This Insurance Applies", is amended to read as follows: This workers compensation insurance applies to bodily injury by accident or disease,including death resulting therefrom.Bodily injury by accident must occur during the policy period.Bodily injury by disease must be caused or aggravated by the conditions of your employment.Your employee's exposure to those conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5.Rate Changes.The premium and rates with respect to the insurance provided by this policy by reason of the designation of California in DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form WC 04 03 01 BB Printed in U.S.A.Page 2 of 2 Item 3 of the Information Page are subject to change if ordered by the Insurance Commissioner of the State of California pursuant to Section 11737 of the California Insurance Code. 6.Long Term Policy.If this policy is written for a period longer than one year,all the provisions of this policy shall apply separately to each consecutive twelve-month period or,if the first or last consecutive period is less than twelve months, to such period of less than twelve months,in the same manner as if a separate policy had been written for each consecutive period. 7.Statutory Provision.Your employee has a first lien upon any amount which becomes owing to you by us on account of this policy,and in the case of your legal incapacity or inability to receive the money and pay it to the claimant,we will pay it directly to the claimant. 8.Part Five,"Premium",E,"Final Premium",is amended to read as follows: The premium shown on the Information Page, schedules,and endorsements is an estimate.The final premium will be determined after this policy ends by using the actual,not the estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy.If the final premium is more than the premium you paid to us,you must pay us the balance.If it is less,we will refund the balance to you.The final premium will not be less than the highest minimum premium for the classifications covered by this policy. If this policy is canceled,final premium will be determined in the following way unless our manuals provide otherwise: a.If we cancel,final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. b.If you cancel,final premium may be more than pro rata;it will be based on the time this policy was in force,and may be increased by our short-rate cancelation table and procedure. Final premium will not be less than the pro rata share of the minimum premium. It is further agreed that this policy,including all endorsements forming a part thereof,constitutes the entire contract of insurance.No condition,provision, agreement,or understanding not set forth in this policy or such endorsements shall affect such contract or any rights, duties, or privileges arising therefrom. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 04 03 03 C (07/18)Printed in U.S.A.Page 1 of 2 Process Date:07/06/22 Policy Expiration Date:06/25/23 ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE OFFICERS AND DIRECTORS COVERAGE / EXCLUSION - CALIFORNIA Policy Number:76 WEG AS9WFU Endorsement Number: Effective Date:06/25/22 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:6th Street Studios 64 W 6TH ST GILROY CA 95020 Name of California Insurer:Sentinel Insurance Company Ltd. If the employer named in Item 1 of the Information Page is a quasi-public or private corporation,this policy applies to all officers and members of boards of directors while rendering actual service for the corporation for pay,as employees, except those excluded below who 1.individually own at least 10 percent of the corporation's issued and outstanding stock, or 2.individually own at least 1 percent of the corporation's issued and outstanding stock if that officer's or member's parent,grandparent,sibling,spouse,or child owns at least 10 percent of the corporation's issued and outstanding stock and that officer or member is covered by a health insurance policy or a health care service plan, or 3.are officers or members of the board of directors of a cooperative corporation organized pursuant to the Cooperative Corporation Law (Corporations Code,Sections 12200 -12704)who state that he or she is covered by both a health care service plan or health insurance policy,and a disability insurance policy that is comparable in scope and coverage, as determined by the Insurance Commissioner, to a workers' compensation policy. If the employer named in Item 1 of the Information Page is a private corporation,or a private cooperative corporation organized pursuant to the Cooperative Corporation Law,this policy applies to an officer or director who is the sole shareholder of the corporation, as an employee, except if excluded below. The insurance under this policy is limited as follows:It is AGREED that,anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: Officers, Directors and Trustees Excluded Title Emily Mcewan Officer DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form WC 04 03 03 C (07/18)Printed in U.S.A.Page 2 of 2 Nothing in this endorsement shall be held to vary,alter,waive or extend any of the terms,conditions,agreements,or limitations of this policy other than as above stated.Nothing elsewhere in this policy shall be held to vary,alter,waive or limit the terms, conditions, agreements or limitations in this endorsement. It is further agreed that "remuneration"when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER,LARGE FINES,AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.). DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Countersigned by Authorized Representative Form WC 04 03 60 B Printed in U.S.A. Process Date:07/06/22 Policy Expiration Date:06/25/23 EMPLOYERS' LIABILITY COVERAGE AMENDATORY ENDORSEMENT - CALIFORNIA Policy Number:76 WEG AS9WFU Endorsement Number: Effective Date:06/25/22 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:6th Street Studios 64 W 6TH ST GILROY CA 95020 The insurance afforded by Part Two (Employers'Liability Insurance)by reason of designation of California in Item 3 of the Information Page is subject to the following provisions: A.“How This Insurance Applies,”is amended to read as follows: A.How This Insurance Applies This employers'liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury means a physical injury,including resulting death. 1.The bodily injury must arise out of and in the course of the injured employee's employment by you. 2.The employment must be necessary or incidental to your work in California. 3.Bodily injury by accident must occur during the policy period. 4.Bodily injury by disease must be caused or aggravated by the conditions of your employment.The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5.If you are sued,the original suit and any related legal actions for damages for bodily injury by accident or by disease must be brought in the United States of America,its territories or possessions, or Canada. C.The “Exclusions”section is modified as follows (all other exclusions in the “Exclusions”section remain as is): 1.Exclusion 1 is amended to read as follows: 1.liability assumed under a contract. 2.Exclusion 2 is deleted. 3.Exclusion 7 is amended to read as follows: 7.damages arising out of coercion,criticism, demotion,evaluation,reassignment, discipline,defamation,harassment, humiliation,discrimination against or termination of any employee,termination of employment,or any personnel practices, policies, acts or omissions. 4.The following exclusions are added: 1.bodily injury to any member of the flying crew of any aircraft. 2.bodily injury to an employee when you are deprived of statutory or common law defenses or are subject to penalty because of your failure to secure your obligations under the workers’compensation law(s) applicable to you or otherwise fail to comply with that law. 3.liability arising from California Labor Code Section 2810.3 which relates to labor contracting. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 04 04 21 Printed in U.S.A.Page 1 of 1 Process Date:07/06/22 Policy Expiration Date:06/25/23 OPTIONAL PREMIUM INCREASE ENDORSEMENT - CALIFORNIA Policy Number:76 WEG AS9WFU Endorsement Number: Effective Date:06/25/22 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:6th Street Studios 64 W 6TH ST GILROY CA 95020 You must provide us,or our authorized representative, access to records necessary to perform a payroll verification audit.If you fail to provide access within 90 days after expiration of the policy,you are liable to pay a total premium equal to 3 times our current estimate of the annual premium for your policy.In addition,if you fail to provide access after our third request within a 90 day or longer period,you are also liable for our costs in attempting to perform the audit unless you provide a compelling business reason for your failure. We will contact you to schedule appointments during normal business hours. We will notify you of your failure to provide access by mailing a certified,return-receipt document stating the increased premium and the total amount of our costs incurred in our attempt(s)to perform an audit.In addition to any other obligations under this contract,30 days after you receive the notification,you will be obligated to pay the total premium and costs referenced above.If, thereafter,you provide access to your records within three years after the policy expires,or within another mutually agreed upon time,and we succeed in performing the audit to our satisfaction,we will revise your total premium and the costs due to reflect the results of the audit. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 04 06 01 B (01/22)Printed in U.S.A. Process Date: 07/06/22 Policy Expiration Date:06/25/23 CALIFORNIA CANCELATION ENDORSEMENT Policy Number:76 WEG AS9WFU Endorsement Number: Effective Date:06/25/22 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:6th Street Studios 64 W 6TH ST GILROY CA 95020 Name of California Insurer:Sentinel Insurance Company Ltd. This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A.of the Information Page. The cancelation condition in Part Six (Conditions)of the policy is replaced by these conditions: Cancelation 1.You may cancel this policy.You must mail or deliver advance written notice to us stating when the cancelation is to take effect. 2.We may cancel this policy for one or more of the following reasons: a.Non-payment of premium; b.Failure to report payroll; c.Failure to permit us to audit payroll as required by the terms of this policy or of a previous policy issued by us; d.Failure to pay any additional premium resulting from an audit of payroll required by the terms of this policy or any previous policy issued by us; e.Material misrepresentation made by you or your agent; f.Failure to cooperate with us in the investigation of a claim; g.Material failure to comply with federal or state safety orders or written recommendations of our designated loss control representatives; h.The occurrence of a material change in the ownership of your business; i.The occurrence of any change in your business or operations that materially increases the hazard for frequency or severity of loss; j.The occurrence of any change in your business or operation that requires additional or different classification for premium calculation; k.The occurrence of any change in your business or operation which contemplates an activity excluded by our reinsurance treaties. 3.If we cancel your policy for any of the reasons listed in (a)through (f),we will give you 10 days advance written notice,stating when the cancelation is to take effect.Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice.If we cancel your policy for any of the reasons listed in Items (g)through (k), we will give you 30 days advance written notice; however,we agree that in the event of cancelation and reissuance of a policy effective upon a material change in ownership or operations,notice will not be provided. 4.If we mail the notice to you,the stated periods of notice and your right to remedy the condition will be extended by 5 days if the place of mailing and your mailing address is within California,10 days if the place of mailing or your mailing address is outside of California and 20 days if the place of mailing or your mailing address is outside of the United States. 5.The policy period will end on the day and hour stated in the cancelation notice. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 99 01 88 (09/20)Printed in U.S.A. Process Date:07/06/22 Policy Expiration Date:06/25/23 COVID-19 REPORTING REQUIREMENT ENDORSEMENT - CALIFORNIA Policy Number:76 WEG AS9WFU Endorsement Number: Effective Date:06/25/22 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:6th Street Studios 64 W 6TH ST GILROY CA 95020 Name of California Insurer:Sentinel Insurance Company Ltd. In addition to the requirements under Part 4,“Your Duties if Injury Occurs”of your policy,if you have five or more employees and an employee that is not described in California Labor Code section 3212.87 tests positive for COVID-19, you are required to report the following information as provided below. Reporting COVID-19 Positive Tests from September 17, 2020 to January 1, 2023 Pursuant to California Labor Code Section 3212.88(i),when you know,or reasonably should know,that an employee has tested positive for COVID-19 between September 17,2020 and January 1,2023,within 3 business days you must report all of the following to your claims administrator in writing via electronic mail or facsimile: (1)An employee has tested positive.For purposes of this reporting,do not provide any personally identifiable information regarding the employee who tested positive for COVID-19 unless the employee asserts the infection is work related or has filed a claim form pursuant to California Labor Code Section 5401. (2)The date that the employee tests positive, which is the date the specimen was collected for testing. (3)The specific address or addresses of the employee’s specific place of employment during the 14-day period preceding the date of the employee’s positive test. (4)The highest number of employees who reported to work at the employee’s specific place of employment in the 45-day period preceding the last day the employee worked at each specific place of employment. Labor Code Section 3212.88(j)states that the intentional submission of false or misleading information or the failure to report the above information as required may subject you to a civil penalty in the amount of up to $10,000 to be assessed by the Labor Commissioner. For the purposes of these reporting requirements, California Labor Code Section 3212.88(m) provides the following: (1)“COVID-19” means the 2019 novel coronavirus disease. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form WC 99 01 88 (09/20)Printed in U.S.A. (2)“Test”or “testing”means a PCR (Polymerase Chain Reaction)test approved for use or approved for emergency use by the United States Food and Drug Administration to detect the presence of viral RNA.“Test”or “testing” does not include serologic testing,also known as antibody testing.“Test”or “testing”may include any other viral culture test approved for use or approved for emergency use by the United States Food and Drug Administration to detect the presence of viral RNA which has the same or higher sensitivity and specificity as the PCR Test. (3)“A specific place of employment”means the building,store,facility,or agricultural field where an employee performs work at the employer’s direction.“A specific place of employment”does not include the employee’s home or residence,unless the employee provides home health care services to another individual at the employee’s home or residence. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 99 03 75 Printed in U.S.A. Process Date:07/06/22 Policy Expiration Date:06/25/23 CALIFORNIA INSTALLMENT FEE DISCLOSURE ENDORSEMENT Policy Number:76 WEG AS9WFU Endorsement Number: Effective Date:06/25/22 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:6th Street Studios 64 W 6TH ST GILROY CA 95020 This endorsement applies only to the insurance provided because California is shown in Item 3.A.of the Information Page. A service fee of $7.00 is charged for each installment when your premium is paid in installments.The service fee is $5.00 per withdrawal when you select an electronic fund transfer payment plan.The service fee will be added to the premium amount shown on your premium billing statement. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 99 06 89 (02/21)Printed in U.S.A.Page 1 of 1 Process Date:07/06/22 Policy Expiration Date:06/25/23 GOODS AND SERVICES ENDORSEMENT Policy Number:76 WEG AS9WFU Endorsement Number: Effective Date:06/25/22 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:6th Street Studios 64 W 6TH ST GILROY CA 95020 Name of Insurer:Sentinel Insurance Company Ltd. This endorsement modifies insurance provided under all Coverage Parts of this Policy. We may offer or make “goods or services”available to you through this underwriting company,a non-insurer subsidiary,or unaffiliated third parties as a part of this policy.The “goods or services”may be provided for a charge, at a discount,on a subsidized basis,or free of charge.In some cases,we may receive a fee from the unaffiliated third parties that provide “goods or services”.We do not warrant or guarantee the “goods or services”provided by third parties,and such third parties shall be solely liable and responsible for the “goods or services”they provide.The “goods or services” offered or made available by us may be modified or discontinued at any time. “Goods or services”means goods,products or services,including but not limited to risk mitigation,safety,and/or loss prevention services or equipment. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form 98456 5th Rev. 12-13 Printed in U.S.A.Page 1 of 2 MAINTAINING YOUR RECORDS FOR AUDIT PURPOSES WHAT IS A PREMIUM ADJUSTMENT? When your Workers'Compensation policy was issued you paid a deposit premium based on the nature of your business and estimates of your payroll.At the end of the policy period,we conduct an audit to compare the estimates against the actual figures and operations. Based on this comparison an adjustment is made.If the actual premium is less than what you already have paid,a refund will be made.If it's more,you will be billed for the difference.These adjustments are subject to any minimum premiums that apply. HOW WILL THE PREMIUM ADJUSTMENT BE MADE? On smaller,less complex operations we may e-mail you, call you,or mail you a request to ask you to provide the information via our online web-based portal,mail or telephone.If we require this information,we will provide an electronic link to,or a paper copy of,the necessary forms for you to complete. On larger,more complex operations one of our Premium Auditors will contact you for an appointment.You will be contacted either by e-mail,telephone or mail.If directed, the auditor will contact your accountant to obtain as much information as possible and contact you at a later time for additional information that may be needed. BASIS OF PREMIUM Remuneration (Payroll) in most states, includes: Payment of:Wages,bonuses,commissions, overtime,*sick pay,vacation pay,*tool allowances,contributions to individual retirement accounts,employee contributions to employee benefit plans. Payments on basis of:Piece work, incentive plans, profit sharing. The value of:Housing furnished to employees,*meals furnished to employees,*store certificates, merchandise and other dollar substitutes. Remuneration does not include: a.Employer contributions to a group insurance or pension plan other than statutory plans of insurance. b.Special awards for individual inventions or discoveries. c.Overtime.* Subcontractors.In the absence of other insurance,most state laws hold a contractor responsible for injuries to employees of subcontractors.At the time of audit Certificates of Insurance must be available for subcontractors with employees,in order to avoid payment of premium. Independent Contractors,without employees,whose duties closely resemble those of an employee,will be considered your employee with the appropriate premium charged. The actual working relationship between you and the Independent Contractor is examined.Items such as,but not limited to:whether the work performed is an integral part of your operations,whether you have the right to control the details of the work,the method of payment, who supplied the materials used,does the person regularly work for others,whose regulatory authority did person operate under,whether the person is involved in a separate and distinct business offering the same services to the public. RECORDS As part of the policy conditions,we are allowed to examine your financial books and records to determine actual exposures and operations.We would appreciate your cooperation in making the needed records available for the auditor's inspection. What Records Will Be Needed? The records needed will vary.In most cases,the Premium Auditor will be able to obtain the necessary audit data from two or more of the following records:Journals, Ledgers,State and Federal Tax Reports,Individual Earning Cards, Checkbooks and Contracts. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form 98456 5th Rev. 12-13 Printed in U.S.A.Page 2 of 2 How You Should Keep Your Records By maintaining your payroll records in accordance with the following guidelines,you might reduce your insurance costs. Overtime.In most states,the amount paid in excess of straight time pay can be deducted if it can be verified in your records.You must maintain your records to show pay separately by employee and in summary by classification of work. *Division of an employee's payroll to more than one classification is not allowed in most states. Exception:For construction,erection or stevedoring operations the payroll of an employee may be allocated to each type of work performed if proper records are kept. Your records must show the number of hours and amount of payroll for each type of work.If you do not keep such a breakdown,the full salary must be charged to the highest rated classification to which the employee is exposed. Executive Officers in most states are considered employees of their corporation and included in the computation of premium.Their remuneration is assigned without division to the actual operation in which they are engaged.If their duties are the same as those of a worker,foreman or superintendent,their payroll is assigned to the classification that develops the highest payroll.Minimum and maximum payrolls apply to executive officers. Automated Records.If your records are automated or you plan to automate in the near future you can obtain maximum benefits by setting up your records to include insurance requirements.Our Premium Auditor will be pleased to assist you in setting up your records.Contact your Hartford Representative if you would like this assistance. NOTE:The contents of this publication are not intended to supersede any definitions or conditions of your policy, the Workers' Compensation Law or any legal rulings. *Your state may have specific rules or exceptions. Please contact your Hartford Representative for details that may apply and answer questions you may have. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form G-3058-1 Printed in U.S.A. POLICY ADJUSTMENT NOTICE The premium we charged for your enclosed Hartford policy was based,in part,on estimates and assumptions related to items such as payroll,sales revenue,and the nature of business operations for the policy period shown.When your coverage period expires,a premium audit will be conducted to ensure the premium you paid for your insurance was accurate.In order to complete the premium audit,when your policy coverage period expires you may receive,via e-mail or US Postal mail,a request to complete an "Insured's Report of Exposure"Form.Alternatively,you may receive notice that a Premium Audit representative will be contacting you to review your records and discuss your business operations over the phone or in person.The purpose of the statement,phone call or visit is for the Premium Audit Department to collect the information required to ensure that the premium you paid for your coverage was accurate. Once the audit is complete,you will receive a Statement of Premium Adjustment which will reflect the amount of your policy auditable premium,and will indicate whether you are owed a refund or if additional premium is due for the policy period shown. If we owe you a return premium,The Hartford will apply the refund amount to any current account balance.If your account is paid in full,or if your refund amount is greater than the current account balance,we will issue you a refund check. You can expect to receive this check within the next 30 days. If you owe us an additional premium, the entire amount will appear as due and payable on your next bill. This amount will appear as "Premium Audit" on your bill. If you have any questions regarding the Premium Audit process, please call your insurance agent. Thank you for doing business with The Hartford. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form WC 66 03 30 O Printed in U.S.A.Page 1 of 2 Customer Privacy Notice The Hartford Financial Services Group, Inc. and Affiliates* (herein called "we, our, and us") This Privacy Policy applies to our United States Operations We value your trust.We are committed to the responsible: a)management; b)use; and c)protection; of Personal Information. This notice describes how we collect,disclose,and protect Personal Information. We collect Personal Information to: a)service your Transactions with us; and b)support our business functions. We may obtain Personal Information from: a)You; b)your Transactions with us; and c)third parties such as a consumer-reporting agency. Based on the type of product or service You apply for or get from us,Personal Information such as: a)your name; b)your address; c)your income; d)your payment; or e)your credit history; may be gathered from sources such as applications, Transactions, and consumer reports. To serve You and service our business,we may share certain Personal Information.We will share Personal Information,only as allowed by law,with affiliates such as: a)our insurance companies; b)our employee agents; c)our brokerage firms; and d)our administrators. As allowed by law,we may share Personal Financial Information with our affiliates to: a)market our products; or b)market our services; to You without providing You with an option to prevent these disclosures. We may also share Personal Information,only as allowed by law, with unaffiliated third parties including: a)independent agents; b)brokerage firms; c)insurance companies; d)administrators; and e)service providers; who help us serve You and service our business. When allowed by law,we may share certain Personal Financial Information with other unaffiliated third parties who assist us by performing services or functions such as: a)taking surveys; b)marketing our products or services; or c)offering financial products or services under a joint agreement between us and one or more financial institutions. We,and third parties we partner with,may track some of the pages You visit through the use of: a)cookies; b)pixel tagging; or c)other technologies; and currently do not process or comply with any web browser’s "do not track"signal or other similar mechanism that indicates a request to disable online tracking of individual users who visit our websites or use our services. For more information,our Online Privacy Policy,which governs information we collect on our website and our affiliate websites,is available at https://www.thehartford.com/online-privacy-policy. We will not sell or share your Personal Financial Information with anyone for purposes unrelated to our business functions without offering You the opportunity to: a)"opt-out;" or b)"opt-in;" as required by law. We only disclose Personal Health Information with: a)your authorization; or b)as otherwise allowed or required by law. Our employees have access to Personal Information in the course of doing their jobs, such as: a)underwriting policies; b)paying claims; c)developing new products; or d)advising customers of our products and services. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form WC 66 03 30 O Printed in U.S.A.Page 2 of 2 We use manual and electronic security procedures to maintain: a)the confidentiality; and b)the integrity of; Personal Information that we have.We use these procedures to guard against unauthorized access. Some techniques we use to protect Personal Information include: a)secured files; b)user authentication; c)encryption; d)firewall technology; and e)the use of detection software. We are responsible for and must: a)identify information to be protected; b)provide an adequate level of protection for that data; and c)grant access to protected data only to those people who must use it in the performance of their job- related duties. Employees who violate our privacy policies and procedures may be subject to discipline,which may include termination of their employment with us. We will continue to follow our Privacy Policy regarding Personal Information even when a business relationship no longer exists between us. As used in this Privacy Notice: Application means your request for our product or service. Personal Financial Information means financial information such as: a)credit history; b)income; c)financial benefits; or d)policy or claim information. Personal Financial Information may include Social Security Numbers,Driver's license numbers,or other government-issued identification numbers,or credit, debit card, or bank account numbers. Personal Health Information means health information such as: a)your medical records; or b)information about your illness, disability or injury. Personal Information means information that identifies You personally and is not otherwise available to the public. It includes: a)Personal Financial Information; and b)Personal Health Information. Transaction means your business dealings with us, such as: a)your Application; b)your request for us to pay a claim; and c)your request for us to take an action on your account. You means an individual who has given us Personal Information in conjunction with: a)asking about; b)applying for; or c)obtaining; a financial product or service from us if the product or service is used mainly for personal,family,or household purposes. If you have any questions or comments about this privacy notice,please feel free to contact us at The Hartford -Consumer Rights and Privacy Compliance Unit, One Hartford Plaza, Mail Drop: HO1-09, Hartford, CT 06155, or at ConsumerPrivacyInquiriesMailbox@thehartford.com. This Customer Privacy Notice is being provided on behalf of The Hartford Financial Services Group,Inc.and its affiliates (including the following as of February 2022), to the extent required by the Gramm-Leach-Bliley Act and implementing regulations: 1stAGChoice,Inc.;Access CoverageCorp,Inc.;Access CoverageCorp Technologies,Inc.;Business Management Group,Inc.;Cervus Claim Solutions, LLC;First State Insurance Company;FTC Resolution Company LLC;Hart Re Group L.L.C.;Hartford Accident and Indemnity Company;Hartford Administrative Services Company;Hartford Casualty General Agency,Inc.;Hartford Casualty Insurance Company;Hartford Fire General Agency,Inc.; Hartford Fire Insurance Company;Hartford Funds Distributors,LLC;Hartford Funds Management Company,LLC;Hartford Funds Management Group, Inc.;Hartford Holdings,Inc.;Hartford Insurance Company of Illinois;Hartford Insurance Company of the Midwest;Hartford Insurance Company of the Southeast;Hartford Insurance,Ltd.;Hartford Integrated Technologies,Inc.;Hartford Investment Management Company;Hartford Life and Accident Insurance Company;Hartford Lloyd's Corporation;Hartford Lloyd's Insurance Company;Hartford Management,Ltd.;Hartford Productivity Services LLC; Hartford of the Southeast General Agency,Inc.;Hartford of Texas General Agency,Inc.;Hartford Residual Market,L.C.C.;Hartford Specialty Insurance Services of Texas,LLC;Hartford STAG Ventures LLC;Hartford Strategic Investments,LLC;Hartford Underwriters General Agency,Inc.;Hartford Underwriters Insurance Company;Heritage Holdings,Inc.;Heritage Reinsurance Company,Ltd.;HLA LLC;HL Investment Advisors,LLC;Horizon Management Group,LLC;HRA Brokerage Services,Inc.;Lattice Strategies LLC;Maxum Casualty Insurance Company;Maxum Indemnity Company; Maxum Specialty Services Corporation;Millennium Underwriting Limited;MPC Resolution Company LLC;Navigators (Asia)Limited;Navigators Corporate Underwriters Limited;Navigators Holdings (UK)Limited;Navigators Insurance Company;Navigators International Insurance Company Ltd.; Navigators Management Company,Inc.;Navigators Management (UK)Limited;Navigators N.V.;Navigators Specialty Insurance Company;Navigators Underwriting Agency Limited;Navigators Underwriting Limited;New England Insurance Company;New England Reinsurance Corporation;New Ocean Insurance Co.,Ltd.;NIC Investments (Chile)SpA;Nutmeg Insurance Agency,Inc.;Nutmeg Insurance Company;Pacific Insurance Company,Limited; Property and Casualty Insurance Company of Hartford;Sentinel Insurance Company,Ltd.;The Navigators Group,Inc.;Trumbull Flood Management, L.L.C.; Trumbull Insurance Company; Twin City Fire Insurance Company; Y-Risk, LLC. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form PN 04 99 06 D Printed in U.S.A. POLICYHOLDER NOTICE PAYROLL RECORD AND AUDIT REQUIREMENTS FOR DUAL WAGE CONSTRUCTION OR ERECTION CLASSIFICATIONS Your policy includes one or more construction or erection classifications.Dual wage classifications are pairs of classifications that describe the same construction or erection operation yet are assigned based upon whether the employee's hourly wage is above or below a specified threshold.Each pair of dual wage classifications contains one "high wage"classification that is assignable to payrolls earned by employees whose regular hourly wage equals or exceeds a specified wage threshold and one "low wage"classification that is assignable to payrolls earned by employees whose regular hourly wage is less than the specified threshold. Payroll Record Requirements The assignment of a high wage classification is contingent on verifying that the employee's hourly wage equals or exceeds the specified wage threshold.The determination of the regular hourly wage for any non-salaried employee must be supported by one of the following sources: o Original time cards or time book entries for each employee.Original records must include the operations performed,the total hours worked each day and the times the employee started and ended each work period throughout the workday.At job locations where all of the employer's operations cease for a uniform unpaid meal period, recording the start and stop times of the uniform break period is not required. o A valid collective bargaining agreement that shows the regular hourly wage rate by job classification of a worker.If using a collective bargaining agreement,the records must include an employee roster by job classification that permits the reconciliation of individual employees to the job classifications set forth in the collective bargaining agreement. The non-salaried employee's regular hourly wage shall be determined by dividing that employee's total remuneration by the hours worked during the pay period,irrespective of whether the employee is paid on an hourly,piecework,production or commission basis. The payroll earned by any non-salaried employees for whom the records specified above are not maintained and/or made available will be assigned to the low wage classification that describes the operations performed. The regular hourly wage of salaried employees is determined by dividing the total annual remuneration by 2000 hours.If an employee is salaried for less than 12 months,the regular hourly wage for the salaried period is calculated on a prorated basis. Audit Requirements If your policy has an effective date on or after January 1,2020 and produces a final premium of $10,500 or more,a physical audit is required at least once a year;if it produces a final premium of less than $10,500 and develops payroll in a high wage classification,a physical audit of the policy is required unless the policy is a renewal and a physical audit was completed for one of the two immediately preceding policy periods.A "physical audit"is defined as an audit of payroll, whether conducted at the policyholder's location or at a remote site,that is based upon an auditor's examination of the policyholder's books of accounts and original payroll records (in either electronic or hard copy form)as necessary to determine and verify the exposure amounts by classification. If you hold a C-39 Roofing Contractor license from the California Contractors State License Board,a physical audit is required on the complete policy period of each policy regardless of the amount of final premium.See California Insurance Code Section 11665(a) for additional requirements regarding the audit of C-39 license holders. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form G-3418-0 PRODUCER COMPENSATION NOTICE You can review and obtain information on The Hartford’s producer compensation practices at www.TheHartford.com or at 1-800-592-5717. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 00 04 22 C (01/21)Printed in U.S.A.Page 1 of 2 Process Date:07/06/22 Policy Expiration Date:06/25/23 TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT Policy Number:76 WEG AS9WFU Endorsement Number: Effective Date:06/25/22 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:6th Street Studios 64 W 6TH ST GILROY CA 95020 Name of California Insurer: This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2019.It serves to notify you of certain limitations under the Act,and that your insurance carrier is charging premium for losses that may occur in the event of an Act of Terrorism. Your policy provides coverage for workers compensation losses caused by Acts of Terrorism,including workers compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, definitions,exclusions,and conditions in your policy,and any applicable federal and/or state laws,rules,or regulations. Definitions The definitions provided in this endorsement are based on and have the same meaning as the definitions in the Act.If words or phrases not defined in this endorsement are defined in the Act,the definitions in the Act will apply. "Act"means the Terrorism Risk Insurance Act of 2002, which took effect on November 26,2002,and any amendments thereto,including any amendments resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2019. "Act of Terrorism"means any act that is certified by the Secretary of the Treasury,in consultation with the Secretary of Homeland Security,and the Attorney General of the United States as meeting all of the following requirements: a.The act is an act of terrorism. b.The act is violent or dangerous to human life, property or infrastructure. c.The act resulted in damage within the United States, or outside of the United States in the case of the premises of United States missions or certain air carriers or vessels. d.The act has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. "Insured Loss"means any loss resulting from an act of terrorism (and,except for Pennsylvania,including an act of war,in the case of workers compensation)that is covered by primary or excess property and casualty insurance issued by an insurer if the loss occurs in the United States or at the premises of United States missions or to certain air carriers or vessels. "Insurer Deductible"means,for the period beginning on January 1,2021,and ending on December 31,2027,an amount equal to 20%of our direct earned premiums during the immediately preceding calendar year. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form WC 00 04 22 C (01/21)Printed in U.S.A.Page 2 of 2 Limitation of Liability The Act limits our liability to you under this policy.If aggregate Insured Losses exceed $100,000,000,000 in a calendar year and if we have met our Insurer Deductible,we are not liable for the payment of any portion of the amount of Insured Losses that exceeds $100,000,000,000;and for aggregate Insured Losses up to $100,000,000,000,we will pay only a pro rata share of such Insured Losses as determined by the Secretary of the Treasury. Policyholder Disclosure Notice 1.Insured Losses would be partially reimbursed by the United States Government.If the aggregate industry Insured Losses occurring in any calendar year exceed $200,000,000,the United States Government would pay 80%of our Insured Losses that exceed our Insurer Deductible. 2.Notwithstanding item 1 above,the United States Government will not make any payment under the Act for any portion of Insured Losses that exceed $100,000,000,000. 3.The premium charge for the coverage your policy provides for Insured Losses is included in the amount shown in Item 4 of the Information Page or in the Schedule below. Schedule State Rate Premium See Attached Schedule DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form WC 66 00 15 A Printed in U.S.A. CALIFORNIA NOTICE CALIFORNIA LABOR CODE 3551 PROVIDES THAT EVERY EMPLOYER SUBJECT TO THE COMPENSATION PROVISIONS OF THIS CODE,EXCEPT EMPLOYERS OF EMPLOYEES DEFINED IN SUBDIVISION (d)OF SECTION 3351,SHALL GIVE EVERY NEW EMPLOYEE,EITHER AT THE TIME OF HIRE,OR BY THE END OF THE FIRST PAY PERIOD, WRITTEN NOTICE OF THE INFORMATION CONTAINED IN SECTION 3550. CALIFORNIA LABOR CODE 3550 PROVIDES THAT EVERY EMPLOYER SUBJECT TO THE COMPENSATION PROVISIONS OF THIS DIVISION SHALL POST AND KEEP POSTED IN A CONSPICUOUS LOCATION FREQUENTED BY EMPLOYEES,AND WHERE THE NOTICE MAY BE EASILY READ BY EMPLOYEES DURING THE HOURS OF THE WORKDAY,A NOTICE WHICH SHALL STATE THE NAME OF THE CURRENT COMPENSATION INSURANCE CARRIER OF THE EMPLOYER,OR WHEN SUCH IS THE FACT,THAT THE EMPLOYER IS SELF-INSURED,AND WHO IS RESPONSIBLE FOR CLAIMS ADJUSTMENT. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form WC 66 02 05 A Printed in U.S.A. NOTICE TO POLICYHOLDER CALIFORNIA WORKERS' COMPENSATION INSURANCE RATING LAWS Pursuant to Section 11752.8 of the California Insurance Code,we are providing you with an explanation of the California workers'compensation rating laws applicable to new and renewal policies with policy effective dates on and after January 1, 1995. 1.The laws requiring all insurers to charge the same minimum rate uniformly to all employers within a given classification has been repealed.Beginning January 1,1995,we will establish our own rates for workers' compensation.Our rates will not be applicable prior to the first normal policy effective date of a policy incepting on or after January 1,1995.Our rates,rating plans and related information are filed with the Insurance Commissioner and are open for public inspection. 2.The Insurance Commissioner can disapprove our rates,rating plans or classifications only if he has determined after public hearing that our rates might jeopardize our ability to pay claims or create a monopoly in the market.A monopoly is defined by law as a market where one insurer writes 20%or more of that part of the California workers' compensation insurance that is not written by the State Compensation Insurance Fund.If the insurance Commissioner disapproves our rates,rating plans or classification,he may order an increase in the rates applicable to outstanding policies. 3.Rating organizations may develop pure premium rates which are subject to the Insurance Commissioner's approval. A pure premium rate reflects the anticipated cost and expenses of claims per $100 of payroll for a given classification.Pure premium rates are advisory only,as we are not required to sue the pure premium rates developed by any rating organization in establishing our own rates. 4.We must adhere to a single,uniform experience rating plan.If you are eligible for experience rating under the plan, we will be required to adjust your premium to reflect your claim history.A better claim history generally results in a lower experience rating modification;more claims,or more expensive claims,generally result in a higher experience rating modification.The uniform experience rating plan developed by the insurance rating organization designated by the Insurance commissioner is subject to the approval of the Insurance Commissioner. 5.A standard classification system developed by the insurance rating organization designated by the Insurance Commissioner is subject to approval of the Insurance Commissioner.The standard classification system is a method of recognizing and separating policyholders into industry or occupational groups according to their similarities and/or differences.We can adopt and apply the standard classification system or develop and apply our own classification system,provided that we can report the payroll,expenses and other costs of claims in a way which is consistent with the standard classification system. 6.Our rates and classifications may not violate the Unruh Civil Rights Act or be unfairly discriminatory. 7.We will provide an appeal process for you to appeal the way we rate your insurance policy.The process will require us to respond to your written appeal within 30 days.If you are not satisfied with the result of your appeal,you may appeal our decision to the Insurance Commissioner. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 POLICY NUMBER:76 WEG AS9WFU NAME OF INSURER:Sentinel Insurance Company Ltd. Form WC 99 00 01 J Printed in U.S.A.Page 1 of 1 Process Date:07/06/22 Policy Expiration Date:06/25/23 Our President and Secretary have signed this policy.Where required by law,the Information Page has been countersigned by our duly authorized representative. Kevin Barnett, Secretary Douglas Elliot, President Includes copyright material of the National Council on Compensation Insurance, Inc. used with its permission. ©2000 National Council on Compensation Insurance, Inc. All Rights Reserved. DELAWARE: Delaware forms have been copyrighted by the Delaware Compensation Rating Bureau Inc. NEW YORK: Includes copyrighted material of the New York Compensation Insurance Rating Board, used with its permission. © 2021 New York Compensation Insurance Rating Board, all rights reserved. NORTH CAROLINA: Includes copyrighted material of the North Carolina Rate Bureau, used with its permission. PENNSYLVANIA: Pennsylvania forms have been copyrighted by the Pennsylvania Compensation Rating Bureau. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 Form WC 55 00 11 D Printed in U.S.A. INSTRUCTIONS EMPLOYEE’S CLAIM FOR WORKERS’ COMPENSATION BENEFITS As of January 1,1990,California employers are required by law to furnish a claim form to an injured worker within one working day of knowledge of a work-related injury or illness (other than First Aid).While it is mandatory for the employer to furnish the claim form to the employee,it is not mandatory for the employee to complete it. The employer should complete sections 9-17,with the exception of section 13 (which reads,"Date employer received claim form").This is to be completed after the claimant has completed his or her portion of the claim form and returned it to you, at which time section 13 should be immediately filled out or date stamped. Penalties can be invoked if employers fail to provide an injured employee an EMPLOYEE’S CLAIM FOR COMPENSATION BENEFITS form or if employers fail to report the claim to the workers’compensation insurance carrier. DO NOT DELAY REPORTING A CLAIM TO THE HARTFORD: Whether or not the employee completes the EMPLOYEE’S CLAIM FOR WORKER’S COMPENSATION BENEFITS,please contact The Hartford’s LossConnect (1-800-327-3636)to report every occupational injury or illness which results in lost time beyond the date of the incident or requires medical treatment beyond First Aid. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7 WC 66 03 09 C Printed in U.S.A. Immediately Report All Work-Related Injuries Through Hartford LossConnect 1)Get the facts regarding the injury. 2)Obtain employee personnel file, whenever possible. 3)Gather information listed below to expedite your call. 4)Call 24 hours a day, 365 days a year at 1-877-383-7022. What Information To Gather Before Placing Your Call During your Hartford LossConnect call,you will be asked questions similar to those on the First Report of Injury,such as those listed below.The more information you have at hand,the less time the call will take and the less need for follow-up. Phone reports take only 10 minutes, and speed the information to open the claim. Employer Account Number or Company Tax ID Number Location Code or Policy Number Injured Worker Injury Name And Address of the Worker When/Where/How Injury Occurred Social Security Number Type of Injury (cut, burn, etc.) Age/Sex/Marital Status Exact Part of Body Injured Number of Dependents Names of Witnesses Date of Hire/Years in Current Position Name/Address of Physician/Hospital Wage Information Anticipated Return to Work Date How Hartford LossConnect Will Speed the Process o Gathers all necessary information over the phone -eliminating the need for you to complete and submit any claim forms. o Triggers any required First Report of Injury notice according to state guidelines. o Forwards First Report of Injury to the state,your company,and the appropriate Hartford Claim Office. DocuSign Envelope ID: 0EFF1435-3AC8-4C59-B604-67B341A8DFC7