DeclarationCal. Super. - 6th Dist.February 5, 2019Electronically Filed by Superior Court of CA, County of Santa Clara, on 6/6/2019 3:12 PM Reviewed By: R. Tien Case #19CV342508 Envelope: 2977884 1O 11 12 13 14 15 16 ‘17 18 19 20 21 22 23 24 25 26 27 28 ELMIRA DANIELYAN, ESQ, BAR #285717 PATENAUDE & FELIX, A.P.C. 6800 Owensmouth Avenue, Suite 290 Canoga Park, CA 91303-42 16 866-784-8084 Attorney for Plaintiff IN THE SUPERIOR COURT OF CALIFORNIA COUNTY OF SANTA CLARA, SANTA CLARA FACILITY LTD. ClV. CASE AMERICAN RECOVERY SERVICE Case N0. 19CV342508 INCORPORATED, A CALIFORNIA CORPORATION AS ASSIGNEE OF STATE COMPENSATION INSURANCE FUND, A DECLARATION IN SUPPORT 0F pUBLIC ENTERPRISE FUND AND DEFAULT JUDGMENT PURSUANT TO INDEPENDENT AGENCY 0F THE STATE 0F EggfigNF 5C8?” PROCEDURE CALIFORNIA, ' Plaintiff, Vs. ROBERT A. MOOMAU DBA MOOMAU PLUMBING, And DOES 1 through 5, Inclusive. Defendant(s). I, L“ 71h JW , hereby declare as follows and can attest that the information provided below is of my own personal knowledge: 1. I am the §l- 4mm!“ mmk for State Compensation Insurance Fund (SCIF). As thedz mama WWWWVF , I have access t0 SCIF‘S computer database. which includes Page 1 DECLARATION IN SUPPORT OF DEFAULT JUDGMENT PURSUANT TO CODE OF CIVIL PROCEDURE SECTION 585 Flle No. 1771351570 / 6000710 1O 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 the contracts between the customer and SCIF, billings, and the entire history 0f each account including the payment history and complaint history. If called upon t0 testify as a Witness, I could and would testify in this matter on my own personal knowledge to all 0f the facts contained herein. 2. I have reviewed this matter and have confirmed through the information contained in SCIF’s computer database that the amounts and parties assigned for collection are correct. Specifically, STATE COMPENSATION INSURANCE FUND, A PUBLIC ENTERPRISE FUND AND INDEPENDENT AGENCY OF THE STATE OF CALIFORNIA assigned to AMERICAN RECOVERY SERVICE INCORPORATED, A CALIFORNIA CORPORATION all 0f its lights, title and interest in the account and policy pefiaining to Defendants. A true and correct copy of the Assignment is attached hereto as Exhibit “A” and incorporated herein by reference. 3. I am intimately acquainted with the internal processes relating to SCIF’s issuance of policies and the calculation 0f premiums due for coverage provided. A11 documents received are imaged and stored in the SCIF computer data base system and are readily accessible to me. I have reviewed the documents in the file as well as all notes in our computer database. It is the policy of SCIF for employees working 0n an insured‘s file t0 confirm the work done by entering such an acknowledgement and/or the infonnation into our database as the activity occurs, including but not limited t0 telephone conversations, any documentary review and invoicing. 4. At the Special instance and request of Defendant, Plaintiffissued Defendant a Workers’ Compensation insurance policy in writing, more paflicularly described as policy number 1953357. The Policy was t0 be effective from 09/01/ 1 4 t0 09/01/ 1 5 and renewed automatically on a yearly basis. Tme and correct copies of the Workers Compensation Policy, Declarations, and Endorsements are incorporated herein and attached hereto as Exhibit “B”. ’ 5. The issued policy was subject to audit of the insured’s annual payroll which occurred after the policy expired, the usual method 0f review employed by SCIF. As a result 0fthe audit 0f the Defendant’s books and records additional premium was generated for the 09/01/14 to 09/01/1 5 policy Page 2 DECLARATION IN SUPPORT OF DEFAULT JUDGMENT PURSUANT TO CODE OF CIVIL PROCEDURE SECTION 585 File No. 17-13515-0 l 6000-10 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 period. The amount of premium outstanding for the insurance coverage provided by SCIF is $12,798.61. Attached hereto and marked Exhibit “C” is a true and correct copy 0f the Final Billing Notice mailed to the Defendant and dated 1 1/24/1 5. However, Defendants, and each of them, made payments after the final invoices were generated totaling $2,400.00. Plaintiff applied $2,200.00 of the credits prior t0 suit being filed, and will apply an $200 to the principal balance due. After all credits are applied, there is now due and owing a balance of $10,398.61. 6. Although SCIF performed a1] its duties and obligations under the policy pursuant t0 the Defendant’s request and has demanded payment, the Defendant has failed and refused to remit payment for the insurance coverage in the amount 0f $10,398.61. 7. There is n0 record 0f any dispute over the balance claimed due by SCIF in the SCIF file, I have reviewed the data in the system and have not located any dispute infonnation whether cataloged in writing 0r in the notes 0f conversations with SCIF employees and the insured 01‘ its representatives. WHEREFORE, declarant prays that the within declaration be accepted by this Court in lieu 0f personal testimony and that my signature, via facsimile, shall be deemed as original. I declare under penalty of perjury under the laws 0f the State 0f Califomia that the foregoing is true and correct. Executed 0n V’ // '/ 7 at Pleasantoniai’f’mnia. /;V Page 3 DECLARATION IN SUPPORT OF DEFAULT JUDGMENT PURSUANT TO CODE OF CIVIL PROCEDURE SECTION 585 File No. 17-13515-0 /6000-1O ASSIGNMENT City: fmw704) . State of California. Date: W7 28, 205/ For valuable consideration, receipt ofwhich is hereby acknowledged, the undersighed does hereby assign unto AMERICAN REC‘QVERY SERVECE, INC, 0f Thousand Oaks, California [“assignee”], our account and claim for collection in the amount of $ /0 39 g» e/ against Mmmm flumgwd #558395} xs/ [“debtfl and we do hereby authorize said assignee to bring action or suit in its own name and to do any and all things necessary to enforce collection of said claim, including engaging legal counsel. The undersigned warrants that the account or claim hereby assigned is a valid debt now fully due and owing to the undersigned fi‘om the debtor named herein, and that there is no just counterclaim or offset against said claim. The undersigned understands that an employee of the undersigned may be required to personally testify as to the basis ofthe account and claim and we do hereby agree to provide said witness upon request.- Legal Name ofAssignor: STADII‘E ”COMPENSATION INSURANCE FUND, a Public Enterprise Fund and Independent Agency 0f the State 0f California Signature: ?f%‘ //1 [Sign and type/p" name here]: MWM K730 [Oflicial title]; 3% WWO Zme72mg ASSIGNMENT Exhibit A pg N STATE CQMPENSATIONImsungrucsFUND WORKERS’ COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INTRODUCTION In return for the payment of the premium and subject to all terms and conditions 0f this policy, we (the State Compensation Insurance Fund) agree with you (the employer named in the Declarations) as follows: GENERAL s'ECTon A. The Policy This policy includes the Declarations and all endorsements and schedules issued by us to be part of this policy and constitutes the entire contract of insurance. It is a contract of insurance between you and us. It is non-transferable. The only agreements relating to this insurance arc stated in. this policy. The terms 0f this policy may not be changed 01' waived except by endorsement issued by us to be part of this policy. You arc responsible for telling us at once when the information contained in this policy is no longer accurate for your operations. No condition, provision, agreement 0r understanding nor stated in this policy contract will affect any rights, duties or privileges in connection with this policy contract. B. Who Is Insured You are insured for your liability to your employees if you arc the employer named in the Declarations, subject to the provisions 0f this policy. If the employer is a partnership, and if you are one of its named partners, you are insured but only in your capacity as an employer of the partnership’s employees. This policy docs not insure the liability of any employer other than the employer named in the Declarations. C. Workers' Compensation Law Workers’ compensation law means the Workers’ Compensation Laws of the State of California. It includes any amendments to that law which are in effect during the policy period. It does not include the provisions of any [aw that provide non-occupational disability benefits. It does not include the provision of any federal law. Page l D. Locations Thislpolicy covers all of your California workplaces listed in the Declarations; and it covers all of your other California workplaces unless you have other insurance 01' are self-insurcd for such California workplaces. E. Who ls Eligible To Receive Workers' Compensation Benefits Your employees (or in the event of their death, their dependents) are eligible for benefits under this policy, except that: '1. Employees who are covered for California workers’ compensation benefits on a policy also affording comprehensive personal liability (CPL) insurance issued to you are not eligible for benefits under this policy. 2. Employees who are excluded under workers’ compensation law are not eligible for benefits under this policy, unless they have been included in the Declarations or by endorsement. If you are named in the Declarations as an Individual Employer or a Husband and Wife Employer, either as individuals 0r a co-partncrship, you are not eligible for benefits under this policy. PART ONE: WORKERS' CDMnENs'Mio‘iN'INSOBANCE. ' A. How This Insurance Applies This workers’ compensation'insurance applies to bodily injury by accident or bodily injury by disease, including resulting death, subject to the following conditions: 1. Bodily injury by accident must occur during [he policy period. 2. 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. B. We Will Pay We will pay promptly when clue to those eligible under this policy the benefits required of you by the workers’ compensation law. ' Exhibit fl pg. \ C. We Will Defend We have the right and duty to defend at our expense any claim 0r proceeding instituted against you before the Workers" Compensation. Appeals Board for benefits payable by this workers" compensation insurance‘ We have the right t0 investigate and settle these claims or proceedings. We have no duty to defend any claim, proceeding 0r suit that is not covered by this workers’ compensation insurance. We have no duty m defend any Claim against you for the discharge, coercion, or discrimination against any employee in violation 0f the law. We may, at your request, defend you using our legal staff against a claim of serious and willful misconduct 01' {01: sanctions instituted before the Workers’ Compensation Appeals Board. D. We Will Also Pay We will also pay the costs enumerated below, in addition to other amounts payable under this workers’ compensation insurance, as part of any claim or proceeding we defend before the Workers’ Compensation Appeals Board: 1. reasonable expenses incurred ar our request, bur not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to twice the amount payable under this workers’ compensation insurance; 3. litigation costs for which we arc responsible; 4. interest on an award as required by law; 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 sle-insurance. AU 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 workcrs’ compensation law including, but not limited to, thosc required because: 1. 0f your serious and willful misconduct; . 2. you knowingly employ 2m employee in violation of law; 3. you fail t0 comply with a health 0r safety law or regulation; 4. you discharge, coerce or discriminate against any employee in Violation of the law; 5. of injury to an employee under the minimum age specified in the workers’ compensation Jaw and illegally employed at the time of injury; Page 2 6. of an increase in indemnity payments due to your failure to provide us with timely and proper notice required by law‘ We may seek reimbursement for any of these amounts paid on your behalf; or 7. of sanctians imposed on you by the Workers’ Compensation Appeals Board. . Recovery From Others We may enforce your rights, and the rights 0f persons entitled t0 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. . 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 01' the bankruptcy or insolvency of you or your estate will not relieve us 0f our duties under this insurance for an injury occurring while this policy is _ in force. 3. We are directly and primarily liable t0 any person entitled to the benefits payable by this insurance, subject to the provisions, conditions and limitations 0f ' this policy. 4. Jurisdiction over you is jurisdiction over us for purposes 0f the workers’ compcnsation law. We are bound by decisions against you under that law, subject to the provisions of this policy that are nor in conflict with that law. 5. Terms of this insurance that conflict with the wotkers’ compensation insurance law in effect during the policy period are changed by this statement to conform to that law. 6. Your employee has a first lien upon any amount which becomes owing t0 you by us on account 0f 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 r0 the claimant. Nothing in these paragraphs'relievcs you of your duties under this policy. PART TWO: EMPLOYER’S LIAB TY LN I . How This Insurance Applies This empioyer’s liability insurance applies to bodily injury by accident 0r bodily injury by disease of an employee. Bodily injury means physical or mental injury, including resulting death. Bodily injury does not include emotional distress, anxiety, discomfort, inconvenience, depression, dissatisfaction or shock to the newous system, unless caused by either a manifest physical injury or a disease with a physical dysfunction 0r condition resulting in treatment by a licensed physician 0r surgeon. Accident is defined as an event that is neither expected nor intended From the Exhibit standpoint of the insured. 1. The bodily injury must arise our of and in the course o‘f the injured employee’s employment by you. 2. The employment must be necessary or incidental t0 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 r0 the conditions causing or aggravating such bodily injuxy by disease must occur during the policy period. 5. If you are sued, the suit and any related legal actions for damages for bodily injury by accident or by disease must be brought under the laws of the State of California. . We Wiil Pay We will pay all sums you legally must pay as damages because 0f bodily injury to your employees eligible for benefits under this policy, provided the bodily injury is covered by this employer‘s liability insurance. The damages we will pay, where recovery is permitted by California law, include damages: 1. for which you are liable r0 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 0f injury to your employee; 2-. for care and loss 0f services; and 3. for the consequential bodily injury that is covered by this employer’s liability insurance to a spouse, child, parent, brother 01' sister of the injured employee; provided that these damages are the direct consequence of bodily injury that arises our of and in the course of the injured employee’s employment by you; and 4. because 0f bodily injury to your employee that arises our of and in the course of employment claimed against you in a capacity other than as employer. . Exclusions This insurance docs not cover: 1. liability assumed under a contract: 2. punitive 0r exemplary damages where insurance for such liability is prohibited by law 0r contrary to public policy; I 3. damages or bodily injury to an empioyee 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“ compensation, occuparidnal disease, unemployment compensation or disability benefits law, the provisions 0f any federal law unless endorsed 0n this policy or any similar law; 5. damages or bodily injury intentionally caused or aggravated by you; Page 3 6. damages 0r bodily injury arising out 0f termination of employment; 7. damages or bodily injury arising out of coercion, criticism, demotio‘n, evaluation, reassignment, discipline, defamation, harassment or humiliation of‘ or discrimination against any employee, or from any personnel practices, policies, acts 0): omissions; or 8. fines or penalties imposed for violation of any JawA . We WiH Defend We have the right and duty to defend, at our expense, any claim, proceeding or suit against you for damages payable by this employer’s liability insurance. We have the right to investigate and settle these claims, proceedings and suits. We may use counsel 0f our choice. We have n0 duty to defend a claim, proceeding or suit that is not covered by this employer’s liability insurance. We have no duty t0 defend 01: continue defending after we have paid our limit of liability under this employer's liability insurance. . We WilI Also Pay We will also pay the costs enumerated below, in addition to other amounts payable under this employer’s liability insurance, as part of any claim, proceeding or suit we defend: 1. reasonable expenses incurred at our request, but nor loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to twice the limit of our liability under this employer’s liability insurance; . litigation costs taxed against you; . interest on a judgment as required by law, and MAO: . expenses we incur. Other Insurance We will not pay more than our share of damages and costs covered by this employer’s liability 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 se.lf-_insurance will be equal until the. loss is paid. . Limit Of Liability Our liability to pay for damages, including defense costs, is limited. Our limit of liability, including defense costs, is shown in the Declarations. It is the most we will pay for all damages covered by this employer‘s liability insurance because of bodily injury to one or more employees in any one accident or occurrence, 0r series of accidents or occurrences, arising out of any one event. We will not pay any claims for damages after we have paid the limit of our liability, including defense costs, under this insurance as explained above. ‘ ' 3 Exhibit 6 pg. H. Recovery From Others We may enforce your rights t0 recover our payment from anyone liable for an injury covered by this employer’s liability insurance. You will do everything necessaly t0 protect those rights for us and to help us enforce them. l. Actions Against Us There will be no right of action against us under this employer’s liability insurance unless: l. you have complied with aJI the terms of this policy; and 2. the amount you owe has been determined with our consent 0r by actual trial and final. judgment. This insurance does nor give anyon'e the right to add us as a defendant in an action against you to determine your liability. PART THREE: COVERAGE OUTSIDE OEZ‘CAUFORNIA This coverage is identical to Part One of this policy. It applies to your employees Who are hired in California and who are eligible for benefits under this policy while they are temporarily working anywhere outside of California on a specific assignment. PART FOUR:»YOUR DUTIES IF INJURY OCCURS Te“ us at once if an injury occurs that may be covered by this policy. Your other duties are listed here: 1. Provide for immediate medical treatment and other services required by thc workers‘ compensation law. 2. Give us 0r our representative the names and addresscs of the injured persons and of witnesses, and other information we may need as required by California Workers’ Compensation Law. 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 01' 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 0r incur expenses, except at your own cost. PART FIVE: PREMIUM A. Manuals All premium for this policy will be determined by our I 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 workers’ compensation insurance.- B. Classifications The Declarations show 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. You arc responsible for telling us at once of any change in classification. ’ ‘ . Premium Calculation 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 0f: 1. a1] your employees eligible for benefits under this policy while engaged in work covered by this policy; and 2. all other persons engaged in work that could make us liable under Part One 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 (he premium basis. This paragraph will not apply if you give us proof that the employers of these persons lawfully secured their workers’ compensation obligations. Premium Payments You will pay all premium when due. . Final Premium The premium shown on the Declarations, schedules and endorsements is an, estimate. The final premium will be determined after this policy ends by using the actual premium basis and the proper classifications, rates and raring plans that lawfully apply to the business and work covered by this policy. If you d0 not provide us with the information necessary to determine the actual premium basis, the estimated premium will bc- used. 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 minimum premium for this policy. 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 minimum premium if we cancel because you fail to comply with the terms and conditions of this policy in regard to payroll records or premium payments. Exhibit 2. If you cancel, final premium will be more than pro rata: it will be based 011 the time this policy was in force, and increased by any short rate cancellation table and procedure in our manuals. 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. . 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. The rating organization designated by the Insurance Commissioner has the same rights we have under this provision. . Rate Changes Premium may be subject to midterm adjustment, for the unexpired term 0f the policy, pursuant t0 the Insurance Commissioner’s power to disapprove rates. PART SIX: CONDITIONS . Inspection We have the right, but are not obliged, t0 inspect your workplaces at any reasonable time. Our inspections relate r0 the .insura bility of the workplaces ancl the premiums to be charged. We. may give you reports on the canditions we find. We may also recommend changes. While they may help reduce losses, we do not undertake to perform the duty 0f 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. The rating organization designated by the Insurance Commissioner has the same rights we have under this provision. . 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. If the first or last consecutive period is less. than twelve months, the provisions of this policy shall apply as if a separate policy had been written for each consecutive period. Until your policy terminates, your deposit premium will be transferred r0 each consecutive policy period to qct as a deposit as if a separate policy had been written. Page 5 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 clays 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 t0 take effect. If certificates of insurance issued by us are in effect, your advance notice to us must be n0 less than the maximum number of clays notice we have agreed to give any one certificate holder when the policy is cancelled. 2. We may cancel this policy for one or more of the following reasons: a. non-payment 0f premium; b. failure to report payroll; c. failure to permit us r0 audit'payroll as required by the terms of this policy or 0f a previous policy issued by us; d. failure to pay any additional premium resulting from an audit 0f payroll required by the tenns of this policy 0r any previous policy issued by us; c. material misrepresentation made by you or your agent; f. failure t0 cooperate with us in the investigation of a claim; . failure t0 comply with federal 0r stare safety orders; .T'G‘Q . failure to comply with written recommendations of our designated loss control representatives; i. the occurrence of a material change in the ownership 0t your business; j. the occurrence of any change in your business 0r operations that materially increases the hazard for frequency or severity of loss; k. the occurrence of any change in your business 0r operations that requires additional 0r different classification for premium calculation; l. the occurrence of any change in yomj business or operations which contemplates an acrivity excluded by our reinsurance treaties. ‘ 3. If we cancel your policy for any 0f the reasons listcd in Items (a) through (f), we will give you '10 days advance written notice, stating when the cancellation is to take effect. Mailing that notice to you at your mailing address shown in the Declarations will. be sufficient r0 prove notice. 4. If we cancel your policy for any of the reasons listed in Items (g) through (I), we will give you 30 days advance written notice. Mailing that notice to you at your mailing address shown in the Declarations will be sufficient to prove notice. In the event of cancellation and reiSSuance of a policy effective upon a material change in ownership or operations, the notice will nor be provided. 5. The policy period will end on the day and hour stated in the cancellation notice. 6. Any of these provisions that conflict with a [aw that controls the cancellation of the insurance in this policy is changed by this statement to comply with that law. . Our Notice To You Mailing documents to you that relate to this policy at the mailing address shown in the Declarations will be sufficient m prove notice. Participating Pkovision-Dividends You will be entitled to participate in any dividend plan applicable to this policy which may be approved for distribution by our Board 0f Directors, with the following exceptions: You will not be allowed t0 participate if: J. you fail to pay any part of the premium for this policy after we request payment in writing, or allow it to remain unpaid for .90 days after we mail a statement of premium t0 you at the mailing address shown in the Declarations; 2. you d0 not keep adequate records of information needed t0 compute premium, 0r do not provide them t0 us when we ask for them; or 3. we must bring suit against you t0 obtain the records necessary for. us to compute premium 0r r0 enforce the collection of all or any part of the premium for this policy. Your participation will be according to the rules adopted by our Board 0f Directors. Under California law it is unlawful for an insurer to promise the future payment of dividends under an unexpired workers‘ compensation policy or to misrepresent the conditions for dividend payment. Dividends are payable only pursuant t0 conditions determined by our Board of Directors or other governing board following policy expiration. To be valid this policy must be signed by our President or Executive Vice President and countersigned by our authorized representative. Countersigned and Issued at San Francisco, California. Kenneth R. Van Laar Thomas E. Ro’we Authorized Representative . President 8C CEO Page 6 STATE comnsnsfincn IN s u nA-N c’E FUND? eFORM L (Rev. 0|/|2) Includes copyright material of the National Council on Compensation Insurance, used with its permission. Exhibit 6 pg. STATE HUME OFFICE SAN FRANCISCO ANNUAL RATING ENDORSEMENT COMPE N SATIONINSURANCE FUND IT Is AGREED THAT THE CLASSIFICATIONS AND RATES PER $100 0F REMUNERATION APPEARINGIN THE CONTINUOUS POLICY ISSUED To THIS EMPLOYER ARE AMENDED As SHOWN BELOW. HERE ARE YOUR NEW RATES FOR THE PERIOD INDICATED. IF YOUR NAME on ADDRESS SHOULD BE CORRECTED OR IF INSURANCE IS NOT NEEDED FOR NEXT YEAR, PLEASE TELL US. IMPORTANT THIS Is NOT A BILL SEND ND MONEY UNLESS STATEMENT IS ENCLOSED HE RATING PERIOD BEGINS AND ENDS AT 12:01AM ACIFIC STANDARD TIME CONTINUOUS ”POLICY 1 95335 7-1 4 RATING PERIOD 9-01f14 TO 9-01-15 ‘MOOMAU PLUMBING DEPOSIT PREMIUM $1,130.00 6443 318T ST N MINIMUM PREMIUM $1,125.00 SAINT PETERSBURG FL 33702 PREMIUM ADJUSTMENT PERIOD ANNUALLY R'NG NAME OF EMPLOYER- MOOMAU, ROBERT A (AN INDIVIDUAL EMPLOYER AND NOT JOINTLY WITH ANY OTHER EMPLOYER) CODE N0. PRINCIPAL WORK AND RATES EFFECTIVE FROM 09- Ul- 14 TO 09- Dl- 15 INTERIM PREMIUM BASE BILLING BASIS RATE RATE* BUILDING CONSTRUCTION 502?-1 MASONRY 30.55 24.84 5028-1 MASONRY 15.85 12.89 5029-1 CONCRETE SEWING OR DRILLING--N.O.C. 13.88 11.29 5140-1 ELECTRICAL WIRING--WITHIN BUILDINGS 6.80 5.53 5183-1 PLUMBING--SHOP AND OUTSIDE U 19.32 15.71 5183-2 REFRIGERATION EQUIPMENT 19.32 15.71 5185-1 AUTOMATIC SPRINKLER INSTALLATION 18.53 15.07 5186-1 AUTOMATIC SPRINKLER INSTALLATION 5.73 4.66 5187-1 PLUMBING--SHOP AND OUTSIDE I U 12.04 9.?9 518?-2 REFRIGERATION EQUIPMENT 12.04 . 9.79 5190-1 ELECTRICAL WIRING--WITHIN BUILDINGS 13.46 10.94 5201-1 CONCRETE 0R CEMENT WORK--POURING 0R 24.41 19.85 FINISHING 0F CONCRETE SIDEWALKS, DRIVE- i WAYS. PATIOS, CURBS 0R GUTTERS 5201-2 CONCRETE 0R CEMENT WORK--POURING 0R 24.41 19.85 FINISHING 0F CONCRETE FLOOR SLABS 5205-1 CONCRETE OR CEMENT WORK--POURING 0R 13168 11.12 TOTAL ESTIMATED ANNUAL PREMIUM $1 125 9A., ~-UNTERSIQNED AND ISSUED AI SAN FRANCISCQ_ SEPTEMBER 3, 25xhlbibLm§mngz 7 STATE COMPENSATIONINSURANCE FUND HUME OFFICE SAN FRANCISCO ANNUAL RATING ENDORSEMENT IT Is AGREED THAT THE CLASSIFICATIONS AND RATES PER $100 0F REMUNERATION APPEARING IN THE CONTINUOUS POLICY ISSUED To THIS EMPLOYER ARE AMENDED As SHOWN BELOW. HERE ARE YOUR NEW RATES FOR THE PERIOD INDICATED. lF YOUR NAME OR ADDRESS SHOULD BE CORRECTED ORIFINSURANCEIS NOT NEEDED FOR NEXT'YEAR,PLEASE TEU_US. 'MPORTANT Tms ls NOT A BILL » CONTINUOUS POLICY 1953357-14 SEND NO MONEY UNLESS STATEMENT IS ENCLOSED HE RATING PERIOD BEGINS AND ENDS AT 12:01AM ACIFIC STANDARD TIME RATING PERIOD 9-01f14 TO 9-01-15 INTERIM PREMIUM BASE BILLING BASIS RATE RATE* 5205-2 5213-1 5222-1 5222-2 5225-1 5403-1 5432-1 5446-1 544T-1 5467-1 5470-1 5474-1 5474-2 5474-3 5482-1 5482-2 5482-3 5434-1 5485-1 DUN SRSLNE FINISHING 0F CONCRETE SIDEWALKS, DRIVE- WAYS, PATIOS, CURBS 0R GUTTERS CONCRETE 0R CEMENT WORK--POURING OR 13.68 11. FINISHING 0F CONCRETE FLOOR SLABS CONCRETE CONSTRUCTION--N.O.C. 14.27 11. CONCRETE CONSTRUCTION--IN CONNECTION 18.16 14. WITH BRIDGES 0R CULVERTS CHIMNEY CONSTRUCTION . 18.16 14. REINFORCING STEEL INSTALLATION 20.83 16. CARPENTRY 36.76 29. CARPENTRY I 14.42 11. WALLBOARD APPLICATION--WITHIN BUILDINGS 21.13 17. WALLBOARD APPLICATION--WITHIN BUILDINGS 12.92 10. GLAZIERS--AWAYIFROM SHOP 26.99 21. GLAZIERS--AWAY FROM SHOP 14.38 11. PAINTING, DECORATING 0R PAPER HANGING I 25.0? 20. WATERPROOFING--OTHER THAN ROOFING 25.0? 20. PAINTING--OIL 0R GASOLINE STORAGE TANKS 25.07 20. PAINTING, DECORATING 0R PAPER HANGING 12.61 10 WATERPROOFING--OTHER THAN ROOFING 12.61 10 PAINTING--OIL 0R GASOLINE STORAGE 12.61 10 PLASTERING bR STUCCO WORK 36.24 29. PLASTERING 0R STUCCO WORK 20;74 16. 8 Q..AND..ISSUED AT SAN FRANC.I..s_c_:Q._S.E._.TEMBER .3, zfixhibibLmmez 0F 12 60 77 ?? 94 89 72 18 51 95 69 38 38 38 .25 .25 .25 4? 86 €31D¢CTEE COMPENSATIONINSURANCE F=LJI\IED HOME OFFICE SAN FRANCISCO ANNUAL RATING ENDORSEMENT IT Is AGREED THAT THE CLASSIFICATIONS AND RATES PER $100 0F REMUNERATION APPEARING IN THE CONTINUOUS POLICY ISSUED To THIS EMPLOYER ARE AMENDED As SHOWN BELOW. HERE ARE YOUR NEW RATES FOR THE PERIOD INDICATED. IF YOUR NAME OR ADDRESS SHOULD BE CORRECTED ORIFINSURANCEIS NOT NEEDED FOR NEXT‘YEAR,PLEASE TEU.US. IMPORTANT THIS IS NOT A BILL - CONTINUOUS 'Poucv 1953357-14 SEND ND MONEY UNLESS STATEMENT IS ENCLOSED HE RATING PERIOD BEGINS AND ENDS AT 12:01AM Acme STANDARD TIME RATING PERIOD 9-01-14 TQ 9-01-15 INTERIM PREMIUM BASE BILLING BASIS RATE RATE* 5538-1 SHEET METAL WORK 16.54 13.45 5542-1 SHEET‘METAL WORK I 10.01 8.14 5552-1 R00FING--ALL KINDS ‘ 67.86 55.18 5553-1 R00FING--ALL KINDS 33.20 25.99 5532-1 STEEL FRAMING--LIGHI GAUGE 35.?6 29.89 5633-1 STEEL FRAMING--LIGHT GAUGE _ 14.42 11.72 6218-1 EXCAVATION--N.0.c. 21.22 17.25 6218-2 GRADING LAND--N.0.C. 21.22 17.25 6218-3 LAND LEVELING--GRADING FARM LANDS 21.22 17.25 5220-1 EXCAVATION--N.0.c. 12.44 10.11 5220-2 GRADING LAND--N.0.C. ‘ 12.44 10.11 6220-3 LAND LEVELING--GRADING FARM LANDS 12.44 10.11 5307-1 SEWER CONSTRUCTION 28.21 22.94 6308-1 SEWER CONSTRUCTION ' 18.07 14.69 6315-1 WATER MAINS 0R CONNECTIONS CONSTRUCTION 21.27 . 17.29 6315-2 GAS MAINS 0R CONNECTIONS CONSTRUCTION 21.27 17.29 5315-1 WATER MAINS 0R CONNECTIONS CONSTRUCTION 11.89 9.67 6316-2 ;67 snu- ~- n a GAS MAINS 0R CONNECTIONS CONSTRUCTION 11.89 9 ********BUREAU NOTE INFORMATION******** FEIN 558294807 {A >UNIERSIGNED_HAI§D..ISSUED AT SAN FRANC.I..5_<_=Q._S.E.B.TEMBER .3, zfixhimbLszng 3 0F STATE HUME OFFICE SAN FRANCISCO ANNUAL RATING ENDORSEMENT COMPE N SATION ‘N 5” ”A N C E IT Is AGREED THAT THE CLASSIFICATIONS AND RATES PER $100 0F REMUNERATION APPEARINGFUN D IN THE CONTINUOUS POLICY ISSUED To THIS EMPLOYER ARE AMENDED As SHOWN BELOW. HERE ARE YOUR NEW RATES FOR THE PERlOD INDICATED. IF YOUR NAME OR ADDRESS SHOULD BE CORRECTED OR IF INSURANCE IS NOT NEEDED FOR NEXT YEAR, PLEASE TELL US. ‘MPORTANT THIS IS NOT A BILL - CONTINUOUS Poucv 1953357-14 SEND N0 MONEY UNLESS STATEMENT IS ENCLOSED H R TING ER D INS AND END AT 12:01AM AEIF§C STAEDAEJS TEES s RATING PERIOD 9-01-14 To 9-01-15 * INTERIM BILLING RATES WILL BE USED 0N PAYROLL REPORTS. THEY TAKE INTO ACCOUNT RATING PLAN CREDITS (0R DEBITS) WHICH WILL APPLY AT FINAL BILLING AND AN ESTIMATE 0F YOUR PREMIUM DISCOUNT AS DETAILED BELOW. RATING PLAN CREDITS fDEBITS] EFFECTIVE FROM 09-01-14 T0 09-01-15 RATING PLAN MODIFIER - 0.81310 ESTIMATED PREMIUM DISCOUNT MODIFIER ' 1.00000 COMPOSITE FACTOR APPLIED T0 BASE RATES T0 DERIVE INTERIM BILLING RATES I 0.81310 ********************************************************************************* * ' * * PREMIUM DISCOUNT SCHEDULE EFFECTIVE FROM 09-01-14 T0 09-01-15 * * ESTIMATED MODIFIED PREMIUM IS DISCOUNTED ACCORDING T0 THE FOLLOWING SCHEDULE: * * FIRST ABOVE ‘ * * $5,000 $5,000 * * 0.02 11.3% * * * i******************************************************************************** THE ESTIMATED PREMIUM DISCOUNT IS BASED 0N AN ESTIMATE 0F YOUR PAYROLL. ACTUAL PREMIUM DISCOUNT APPLIED AT FINAL BILLING WILL BE BASED 0N THE ACTUAL PAYROLL REPORTED 0N YOUR POLICY AND SUBJECT T0 AUDIT. \Q 2mT§RSI§mp_..AND..ISSUED AT SAN FRANC.I_s__Q_§.E._.-rmvxsER .3, zfixhibébugLLHpg. 4 0F STATE COMPEN SATIONINSURANCE FUND HOME OFFICE SAN FRANCISCO ANNUAL RATING ENDORSEMENT IT Is AGREED THAT THE CLASSIFICATIONS AND RATES PER $100 0F REMUNERATION APPEARING IN THE CONTINUOUS POLICY ISSUED To THIS EMPLOYER ARE AMENDED As SHOWN BELOW. CONTINUOUS POLICY 1953357-14 IF YOU HAVE ANY QUESTIONS. PLEASE CONTACT YOUR LOCAL STATE FUND OFFICE BELOW: CSC - POLICY AT VACAVILLE 1020 VAQUERO CIRCLE VACAVILLE , CA 95688 (8??) 405-4545 _ When countersigned by a duly authorized officer or representative of the State Compensation Insurance Nothing herein contained shall be held to vary, alter, waive or extend any of the terms, conditiohs agreements or limitations of the Poticy other than as herein stated. Fund, these declarations shall be valid and form part of the PolicyV mfigy / {mm AUTHORIZED REPRESENTATIVE PRESIDENT AND CEO INTERSIGNED AND ISSUED AT SAN FRANCISCO SEPTEI‘BER 3, 2014 POLICY PAGE 5.0F CIF FORM 10963A (REV.7-2014) EXhibit pa. ‘\ I . $12,798.61 12/04/15 OMPENSATlQN' ‘1 N S U R A N C E m 10000919533571400000112415320000000001279861117 P.O. BOX 7441 N FRANCISCO. CA 94120-7441 11/24/15 3 A 2 MOOMAU PLUMBING Gmmp o POLICY/UNlT l 9 5 3 3 5 7 _ 1 4 0 . 1177 BRANHAM LN # 152 E SAN JOSE, CA 95118 NA.R 1 CHECK BOX AT LEFT FOR ADDRESS CHANGE ADDRESS CITY. STATE ZIP HEPORT/AUDRT PERIOD - CODE STANDARD CLASSIFICATION - PAYROLL RATE PREMIUM FROM TO 9/01/14 9/01/15 5183-1 PLUMBING/SHOP-OUT<$26HR 41397.93 19.32 7,998.08 9/01/14 9/01/15 5183-2 No PAYROLL REPORTED .00 19.32 .00 9/01/14 9/01/15 5187-1 PLUMBING/SHOP-OUT>-$26HR 68690.15 12.04 8,270.29 9/01/14 9/01/15 5187-2 N0 PAYROLL REPORTED .00 12.04 .00 9/01/14 9/01/15 5403-1 No PAYROLL REPORTED .00 36.76 .00 TOTAL BASE PREMIUM 16,268.37 RATING PLAN MObIFIER APPLIED .81310 - 13,227.81 PREMIUM DISCOUNT MODIFIER APPLIED .92971 12,298.03 TOTAL PREMIUM FOR 9/01/14 - 9/01/15 ‘ 12,298.03 A COPY OF THIS BILL HAS BEEN SENT TO THE BROKER LISTED ON YOUR POLICY N R 12,298.03 VIOUS BILLS NOT PAID . CIGA SURCHARGE 2.25002 OF 12,298.03 LESS 25.31 - 251.40 OSHF( .216602) + LEC ( .245202) - .4618OZ OF 12,298.03 LESS 0.00 - 56.79 UEBTC .160302) + SIBT ( .129102) - .289402 OF 12,298.03 LESS 0.00 - 35.59 WCA (1.224702) + WCFA ( .254402) - 1.479102 OF 12,298.03 LESS PREVIOUSLY PAID WCA/WCFA SURCHARGE 25.10 ' 156.80 ASE DISREGARD IF PAYMENT HAs BEEN MADE. - -> 1125 1953357-14 PAY THIS AMOUNT ' $12,798.61 5T? P.o.Box 7441 . . . UND‘ SANFRANCISCQ-CA94120-7441 See the back for Important payment Instructions. (REV. 12-13) Exmbit 0 pg k
