Agmt25 A Pe Pe, Inc. (2616 Broadway)

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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY POLICY INFORMATION PAGE ENDORSEMENT Insured: A Pa Pe, Inc. Policy No: Policy Period: 12/27/2024 to 12/27/2025 Endorsement No: Carrier Name: Technology Insurance Company, Inc. Endmt Effective: The following item(s) ❑ Insured's Name (WC 89 06 01) ❑ Policy Number (WC 89 06 02) ❑ Effective Date (WC 89 06 03) ❑ Expiration Date (WC 89 06 04) ❑ Insured's Mailing Address (WC 89 06 05) ❑ Experience Modification (WC 89 04 06) ❑ Producer's Name (WC 89 06 07) ❑ Change in Workplace of Insured (WC 89 06 08) ❑ Insured's Legal Status (WC 89 06 10) ❑ Item 3.A. States (WC 89 06 11) is changed to read: Authorized Rep: TES4516027 1 2/4/2025 ❑ Item 3.13. Limits (WC 89 06 12) ❑ Item 3.C. States (WC 89 06 13) ® Item 3.D. Endorsement Numbers (WC 89 06 14) ® Item 4.* Class, Rate, Other (WC 89 04 15) ❑ Interim Adjustment of Premium (WC 89 04 16) ❑ Carrier Servicing Office (WC 89 06 17) ❑ Interstate/Intrastate Risk ID Number (WC 89 06 18) ❑ Carrier Number (WC 89 06 19) ❑ Issuing Agency/Producer Office Address (WC 89 06 25) Specific Waiver of subrogation is added to the policy in favor of: The City of Redwood City 1017 Middlefield Road Redwood City 94061 CA Class code 9080 - 1000 Start Date: 2025-02-04 to End Date: 2025-12-27 Adding form(s): WC990001 E_Class WC990001 E_PmtSched ATTY/AGR.2025.207/A Pa Pe, Inc. (2616 Broadway) (Page 39 of 55)