2019/07/01 Trinet Group, Inc. L/C/F SCG Spicer Consulting Group LLC Workers' Compensation and Employers Liability InsuranceWC 00 00 01A (05/88)Copyright 1987 National Council on Compensation Insurance
INSURED COPY
ISSUING COMPANY Workers' Compensation
and Employers Liability
Insurance Policy
Information Page
ACE AMERICAN INSURANCE COMPANY
NCCI CARRIER CODE
12165
POLICY NUMBER New X Renewal Rewrite
Workers' Compensation and Employers Liability Insurance Policy
Symbol:WLR Number:C6 62 07 91 2
PREVIOUS POLICY NO.Individual Partnership Association
Symbol:WLR Number:C65625878 X Corporation Joint Venture Other Legal Entity
Item 1.Inter/Intrastate ID No.:TRINET GROUP, INC.
Named L/C/F SCG SPICER CONSULTING GROUP LLC
9000 TOWN CENTER PARKWAY
BRADENTON FL 34202
Insured Federal Employer ID No.:953359658
Mailing
Address
Employer's ID No.:
PIIC CODE:6282
For other named insured see Extension of Information Page – Schedule of Named Insured, WC 99 99 99 A
For other workplaces see Extension of Information Page – Schedule of Other Workplaces, WC 99 99 99 B
Item 2.Policy period:From 07-01-2019 To 07-01-2020 12:01 A.M.,standard time at the named insured's mailing address.
Item 3A.Workers' Compensation Insurance:Part One of the policy applies to the Workers' Compensation Law of the states listed here:
CA
Item 3B.Employers Liability Insurance:Part Two of the policy applies to work in each state listed in Item 3A.
The limits of our liability under Part Two are:Bodily Injury by Accident $2,000,000 each accident
Bodily Injury by Disease $2,000,000 policy limit
Bodily Injury by Disease $2,000,000 each employee
Item 3C.Other States Insurance:Part Three of the policy applies to the states, if any, listed here:
ALL STATES EXCEPT
ND,OH,WA,WY,
AND STATES DESIGNATED IN ITEM 3.A
Item 3D.This Policy includes these endorsements and schedules:
See schedule of Forms and Endorsements WC999999D
Item 4.The premium for this policy will be determined by our Manual of Rules,Classifications,Rates and Rating Plans.All information
required below is subject to verification and change by audit.
SEE EXTENSION OF INFORMATION PAGE –CLASSIFICATIONS
If indicated here, interim adjustments of premium will be made:Minimum Premium collected in CA $
Semi-Annually Quarterly Monthly Total Estimated Premium $
Deposit Premium $
PRODUCER NAME AND MAILING ADDRESS
USI INSURANCE SERVICES LLC
2601 SOUTH BAYSHORE DRIVE
16TH FLOOR SUITE 1600
COCONUT GROVE FL 33133
PRODUCER CODE:Z05455 13-3771734 DAU
MARKETING OFFICE:DALLAS BRANCH
ISSUE DATE:07/08/2019
Authorized Representative