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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />POLICY INFORMATION PAGE ENDORSEMENT <br />The following item(s) <br />Insured's Name (WC 89 06 01) <br />Policy Number (WC 89 06 02) <br />Effective Date (WC 89 06 03) <br />Expiration Date (WC 89 06 04) <br />Insured's Mailing Address (WC 89 06 05) <br />Experience Modification (WC 89 04 06) <br />Producer's Name (WC 89 06 07) <br />Change in Workplace of Insured (WC 89 06 08) <br />Insured's Legal Status (WC 89 06 10) <br />Item 3.A. States (WC 89 06 11) <br />is changed as follows: <br />Action Type Previous Value <br />Item 3.6. Limits (WC 89 06 12) <br />Item 3.C. States (WC 89 06 13) <br />WC890600B <br />(Ed. 7-01) <br />X Item 3.D. Endorsement Numbers (WC 89 06 14) <br />Item 4. Class, Rate, Other (WC 89 04 15) <br />Interim Adjustment of Premium (WC 89 04 16) <br />Carrier Servicing Office (WC 89 06 17) <br />Interstate/Intrastate Risk ID Number (WC 89 06 18) <br />Carrier Number (WC 89 06 19) <br />Issuing Agency/Producer Office Address (WC 89 06 25) <br />New Value <br />Add <br />Waiver of <br />N/A <br />Type: Individual <br />Subrogation <br />State: CA <br />Class Code: 8078 Payroll: 0 <br />Subrogant Name: The City of Redwood City and its <br />council, officers, agents, and employees <br />Subrogant Address: 1017 Middlefield Rd <br />Subrogant City: Redwood City <br />State: CA <br />Postal Code: 94061 <br />Effective Date: 08/11/2025 <br />Expiration Date: 08/01/2026 <br />Total Estimated Annual Premium $1,219.00 Premium Adjustment $287.00 <br />Minimum Premium $274.00 Deposit Premium $1,219.00 <br />All other terms and conditions of this policy remain unchanged. <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br />Endorsement Effective: 08/11/2025 <br />Insured: Estellato Tre Inc <br />Policy No. MWCO240900-01 Endorsement No. <br />Insurance Company: Markel Insurance Company Countersigned by <br />WC890600B © 2001 National Council on Compensation Insurance, Inc. <br />(Ed. 7-01) <br />Premium $(See Attached) <br />I��I��II I� �III��I IIII ��II� IIII �I�II ��II� IIII ��III ��II II��II ��I�I III I�I <br />MWCO240900-01 <br />Page 1 of 1 <br />ATTY/AGR.2025.342/Gaffe Stellato (816 Middlefield Road - Caffe Stellato) (Page 22 of 27) <br />