Complaint Limited 10K and 25KCal. Super. - 6th Dist.May 3, 2021lO ll 12 l3 14 15 16 l7 18 19 20 21 22 23 24 25 26 27 28 E-FILED 5/3/2021 1:12 PM Clerk of Court Superior Court of CA, Count of Santa Clara 21CV 81216 GABA GUERRINI LAW CORPORATION Reviewed By: R. Cachux Rodolfo Gaba, Jr. (230475) Ryan M. Arakawa (315181) John D. Guerrini (190972) 8583 Irvine Center Drive o Suite 500 Irvine, California 92618-4298 888-391-1228 Phone 949-207-7108 Facsimile updates@qqlc.law Attorney for Plaintiff AMGUARD INSURANCE COMPANY [54619] SUPERIOR COURT 0F THE STATE 0F CALIFORNIA FOR THE COUNTY 0F SANTA CLARA LIMITED CIVIL JURISDICTION AMGUARD INSURANCE COMPANY, Case No.: 21CV381216 Plaintiff, COMPLAINT FOR FAILURE To PAY INSURANCE PREMIUMS DEMAND: $13,298.00 LIMITED CIVIL CASE vs. OMEGA GLOBAL TECHNOLOGIES, |NC., A CORPORATION; DOES 1-100, inclusive, Defendant J Plaintiff AMGUARD INSURANCE COMPANY (“Plaintiff”) alleges the following causes of action against OMEGA GLOBAL TECHNOLOGIES, |NC., A CORPORATION; and DOES 1-100, inclusive (the “Defendant”), as follows: 1. Plaintiff is, and at all times relevant was, a corporation, organized and existing under and by virtue of the laws of the state 0f its incorporation. 2. Plaintiff alleges on information and belief that the Defendants, or some of them, maintain a principal place of business within the above-referenced County and Judicial District. COMPLAINT - l lO ll 12 l3 l4 15 l6 l7 18 l9 20 21 22 23 24 25 26 27 28 3. The true names and capacities, whether individual, corporate, associate, or otherwise, of Defendants Does 1-100, inclusive, are unknown to Plaintiff, who therefore sues said Defendants by such fictitious names. Plaintiff alleges on information and belief that each of the Defendant designated herein as a fictitiously named defendant is, in some manner, responsible for the events and happenings referred to, either contractually or tortiously, and/or that such fictitiously named Defendant claim some right, title or interest to the property described herein below and/or that such fictitiously named Defendant are liable in some manner for the obligation described herein below. When Plaintiff ascertains the true names and capacities of Does 1-100, Plaintiff will amend this complaint accordingly. 4. Plaintiff alleges on information and belief that at all times herein mentioned, all Defendants named herein each acted in concert and conspired with or aided and abetted each other to do the acts complained of in this complaint, and that each defendant acted as an agent for the other at all times. 5. Plaintiff alleges on information and belief that the obligation sued upon is not subject to the provisions of Civil Code '2984.4 or Civil Code '1812.10. 6. On or about October 26, 2016, Defendants, and each of them, applied for a insurance policy from the Plaintiff. 7. Subsequently, Plaintiff did in fact issue policy No. OMWC792587 for the period October 26, 2016 to October 26, 2017 to the Defendants, and each of them. 8. On or about February 10, 2020, Defendants became indebted to Plaintiff in the sum of $13,298.00 for unpaid premiums under the policy. A true and correct copy 0f the Invoice is attached hereto as Exhibit 1. 9. Although demand therefore has been made, no part of $13,298.00 has been paid, and said balance, together with interest thereon at the maximum statutory rate of 10.00% per annum, from February 10, 2020, is now due, owing and unpaid. COMPLAINT - 2 lO ll 12 l3 14 15 16 l7 l8 19 20 21 22 23 24 25 26 27 28 WHEREFORE, Plaintiff prays forjudgment in its favor and against Defendants, and each ofthem, and Does 1-100, as follows: 10. For damages in the principal sum of $13,298.00; 11. For interest thereon at the rate of 10.00% per annum, from February 10, 2020; 12. For costs of suit incurred herein; 13. For such other and further relief as this court may deem just and proper. Dated: April 28, 2021 GABA GUERRINI LAW CORPORATION r‘) By' 1‘ 1% 'Rodolfo Gaba, Jr.‘ Attorneys for Plaintiff AMGUARD INSURANCE COMPANY COMPLAINT - 3 EXHIBIT “1” P.O.BOX A-H, 39 Public Square v / - W'lkes-Ba e PA 18701-2509 \v‘/ BerkShlre Hathaway 570-825-990l0 (Toll-;:eé 800-673-2465) 0/3“GUARD Insurance premiumaudit@guard.com[II Companies Fax: 570-829-4587 OI www.guard.com Agency Omega Global Technologies TAMMIE PEREIRA INSURANCE SERVICES, INC. 921 Berryessa Road 1606 S El Camino Real #20 San Mateo, CA 94402 San Jose, CA 95113 Revised Final Audit of Your Workers' Compensation Policy with AmGUARD Insurance Company Policy Number OMWC792587 At this time, we are forwarding audit information for the insurance policy shown above. As you can see, this recap is seIf-explanatory and enables you to quickly review the transaction. However, you should also be aware that the amount clue on any current Berkshire Hathaway GUARD Insurance Companies policy may be adjusted to reflect the results 0f this audit of your expired term. We suggest you place the enclosed document with the balance of the policy. If you have any questions, please feel free to contact us at 800-673-2465. Policy Period From October 26, 2016 to October 26, 2017, 12:01 AM, standard time at the insured's mailing address. Type of Endorsement and Party Requesting the Change Payroll - The Policyholder Workers' Compensation Specialists INTERNAL USE 7A MGA : OMWC792587 Date : 02/10/2020 Endorsement Recap DECTO : I / Workers' Comgensation and Emgloyer's Liability Policy y/ - AmGUARD Insurance Company - A Stock Co. \Va BerkSh're Hathaway Policy Number OMWC792587 ‘\ $24; GUARD é::;::i:: "zzmzazszi Policy Information Page - Revised Final Audit OI [1Named Insured and Mailing Address Agency Omega Global Technologies TAMMIE PEREIRA INSURANCE SERVICES, INC. 322%) Berryessa Road 1606 S EI Camino Real San Mateo, CA 94402 5a“ 3°5e' CA 95113 Agency Code: COICAA22 Federal Employer's ID 27-3023143 Insured is Corporation [2] Policy Period From October 26, 2016 to October 26, 2017, 12:01 AM, standard time at the insured's mailing address. Revision Revision #5, effective on the date shown below, 12:01 AM, standard time, changes the listed items. A|| other terms and conditions of the policy remain unchanged. [3] Coverage A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the following states: California 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 $11000/000 Bodily Injury by Disease - each employee “10001000 Bodily Injury by Disease - policy limit “10001000 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, West Virginia, and Wyoming. D. This policy includes these endorsements and schedules: See Extension of Information Paqe - Schedule of Forms - WC 040004 [4] Premium The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. AII required information is subject to verification and change by audit. (Continued on another page) Total Policy Premium $ 24,432 Total Surcharges/Assessments $ $735.00 Total Cost $ $25,167.00 INTERNAL USE 7A Page - 1 - Endorsement MGA : 0ch792587 Date : 02/10/2020 WC 99 06 09 P.O. Box A-H o 39 Public Square oWilkes-Barre, PA 18703-0020 o www.guard.com Endorsement WC 99 06 09 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY wc o4 oo 04 (Ed. 7-93) EXTENSION OF INFORMATION PAGE Schedule of Forms ITEM 3D pOUCY NQ_ OMWC792587 Form Numbers Agglicable States PN049901F - CA YOUR RIGHT TO RATING AND DIVDEND INFO PN0499OZB - CA POLICYHOLDER NOTICE - WC RATING LAWS PNO49904 - CA INS. GUARANTEE ASSOC.(CIGA) SURCHARGE WCOOOOOOC - STANDARD POLICY WCOOOOOlA - INFORMATION PAGE WCOOO421D - CATASTROPHE(OTHER THAN CERT ACTS OF TERR WCOOO4ZZB - TERR RISK INS PROG REAUTHORIZATION ACT WCO40004 - CA EXT OF INFO PAGE-SCHEDULE OF FORMS WC040301B - POLICY AMENDATORY ENDORSEMENT-CALIFORNIA WCO40303A - CA OFFICERS & DIRECTORS COVRG/EXCLUSION WC040310 - CA DUTY TO DEFEND WCO40410 - CA ESTIMATED ANNUAL PREMIUM ENDORSEMENT WC040422 - CALIFORNIA SHORT-RATE CANCELLATION END'T WCO40601A - CA CANCELLATION ENDORSEMENT WC990000 - AUTHORIZATION AND A'I'I'ESTATION END'T WC990014 - CALIFORNIA CHANGES - AMENDATORY END'T Page ' 2 ' Endorsement WC 99 06 09 ©1998 by the Workers’ Compensation Insurance Rating Bureau of California. All rights reserved. / Workers' Comgensation and Emgloyer's Liability Policy y/ - AmGUARD Insurance Company - A Stock Co. \V; BerkSh're Hathaway Policy Number OMWC792587 049GUARD Insurance Renewalof NEWIII Companies NCCI No. [21873] Policy Information Page - Revised Final Audit O [4] Premium (cont.) California Classification Code Premium Basis: Rate per Annual Total $100 Premium Annual Remuneration Remuneration Effective: 10/26/2016-10/26/2017 STORE: WHOLESALE NOC 8018 256,362.00 10.49 26,892 SALESPERSONS-OUTSIDE 8742 326,527.00 0.75 2,449 CLERICAL OFFICE EMPLOYEES NOC 8810 101,080.00 0.61 617 Territorial Rating, Bay Area 0.95 -1,498 Schedule Modification 9.5% -2,704 Premium Discount 7.09% -1,826 Total Annual Premium for CA 23,930 Policy Totals Total Standard Premium for California 23,930 Catastrophe 9741 0.02 683,969 137 Expense Constant 160 Terrorism CA 9740 0.03 683,969 205 Minimum Premium CA $1,735 Total Annual Premium 24,432 CA Fraud Surcharge 10/26/2016-10/26/2017 0,1741% 43 CA OSHF Assessment 10/26/2016-10/26/2017 O.1925% 47 CA CIGA Surcharge 10/26/2016-10/26/2017 2.0000% 489 CA WCARF Assessment 10/26/2016-10/26/2017 O.3433% 84 CA UEBTF Assessment 10/26/2016-10/26/2017 0.0532% 13 CA LECF Assessment 10/26/2016-10/26/2017 0.1215% 3O CA SIBTF Assessment 10/26/2016-10/26/2017 0.1191% 29 Total Cost for OMWC792587 25,167 wLUSE-7A. Page - 3 - Endorsement MGA : OMWC792587 Date : 02/10/2020 WC 99 06 09 P.O. Box A-H o 39 Public Square oWilkes-Barre, PA 18703-0020 o www.guard.com Workers' Comgensation and Emgloyer's Liability Policy AmGUARD Insurance Company - A Stock Co._ / . ya BerkSh're Hatlrllsavgi}; Policy Number OMWC792587 UV R I fNEW [iAi GUARD Companies NcggeNvf [31873] Policy Information Page - Revised Final Audit OI Policy Reconciliation Page - Final Audit Payments applied $(11,869) Final audit adjustment $ 13,298 Balance clue $ 13,298 Policy cost prior to final audit $ 11,869 Billing fees charged $ 0 (The balance due will be billed separately.) INTERNAL USE 7A Page _ 4 _ Endorsement MGA : OMWC792587 Date : 02/10/2020 WC 99 06 09 P.O. Box A-H o 39 Public Square oWilkes-Barre, PA 18703-0020 o www.guard.com
