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I MPLOYFRSI <br />Workers' Compensation and Employers Liability <br />Insurance Policy <br />EMPLOYERS PREFERRED INS. CO.Policy <br />Number From olicy Period <br />A Stock Company <br />EIG 5504980 01 <br />02/21/2025 02/21/2026 <br />12:01A.M.Standd rd Time at the address ofthe <br />Insured as stated�ierein <br />Transaction <br />AMENDED DECLARATIONS Effective: 02/21/2025 <br />NCCI Carrier # 31283 WCIRB CARRIER# 00920 PRIOR POLICY NUMBER EIG550498000 <br />1. Named Insured and Address <br />Agent <br />BARREL DOG, INC. <br />SEMSEE CORP 0003364 <br />DBA BLACKSMITH BAR <br />594 DEAN ST FLOOR 3 <br />138 LOMA VISTA DR <br />BROOKLYN, NY 11238 <br />BURLINGAME CA 94010 <br />Telephone: 3322338762 <br />Customer # <br />Carrier # <br />FEIN # <br />Risk ID # <br />1 <br />Entity of Insured <br />31283 <br />472288322 <br />9622117 <br />CORPORATION <br />Additional Locations: <br />2. The Policy Period is from 02/21/2025 to 02/21/2026 12:01 a.m. Standard Time at the Insured's mailing address. <br />3. A. Workers Compensation Insurance: Part ONE of the policy applies to the Workers Compensation Law of the states <br />listed here: CA <br />B. Employers Liability Insurance: Part TWO of the policy applies to work in each state listed in Item 3A. <br />The limits of our liability under Part TWO are: <br />Bodily Injury by Accident $ 1,000,000 each accident <br />Bodily Injury by Disease $ 1,000,000 policy limit <br />Bodily Injury by Disease $ 1,000,000 each employee <br />C. Other States Insurance: Part THREE of the policy applies to the states, if any, listed here: <br />All states except ND, OH, WA, WY and states listed in item 3.A. <br />D. This policy includes these endorsements and schedules: See attached schedule. <br />4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans. <br />All information required below is subject to verification and change by audit. <br />SEE EXTENSION OF INFORMATION PAGE <br />Minimum Premium $ 750 <br />Assessments and Taxes $ <br />❑ This is a Three Year Fixed Rate Policy <br />Premium Adjustment Period: ® Annual; <br />Countersigned this Day of , <br />Issued Date: 06/19/2025 <br />Issuing Office EMPLOYERS PREFERRED INS. CO. <br />P.O. BOX 539003 <br />HENDERSON, NV 89053-9003 <br />Issued Date 06/19/2025 <br />WC990630 (5/98 Ed.) <br />Expense Constant $ 160 <br />Premium Discount $ <br />Total Estimated AnnualPremium $ 4,297 <br />❑ Semiannual; ❑ Quarterly; ❑ Monthly <br />INSURED COPY <br />Page 1 of 4 <br />Authorized Representative <br />ATTY/AGR.2025.229/Barrel Dog, Inc. dba Blacksmith (2048 Broadway - Blacksmith) (Page 21 of 44) <br />