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Berkshire Hathaway Direct Insurance Company Policy Number: CP140206066P2024 A Stock Company New Policy Renewal of Policy Information Page 1. Named Insured and Mailing Address: City Pub, Inc. dba City Pub 2620 Broadway St Redwood City, CA, 94063-1533 Federal Employer's ID: 94-3126258 Risk ID Number: Business Description: Bar and Grill r2. Policy Period: From March 15, 2024 12:01 AM, to March 15, 2025 12:01 AM, standard time at the insured's mailing address listed on the Summary. 3. Coverage: A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the following states: All States Except Monopolistic States B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: • Bodily Injury by Accident - each accident: $1,000,000 • Bodily Injury by Disease - each employee: $1,000,000 Bodily Injury by Disease - policy limit: $3,000,000 C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming. D. This policy includes these endorsements and schedules: • WC OOOOOOC - STANDARD POLICY WC 3P CA DEC A - INFORMATION Additional Forms: WC040604A 4. Premium: The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. All required information is subject to verification and change by audit. (Continued on another page.) Total Estimated Policy Premium: $12,816.00 Total Surcharges / Assessments: $775.00 Total Estimated Cost: $13,591.00 Issuing Office: 1314 Douglas Street, Suite 1400, Omaha, NE 68102-1944 WC 3P CA DEC A-220 1 ATTY/AGR.2024.149/City Pub (2620 Broadway) (Page 33 of 36)