ACCEPTED ANY_ALL WC 07.01.25-07.01.26.pdf

Information Page

Insurer: Key Risk Insurance Company

NCCI Carrier #: 37044 9301 Innovation Drive, Suite 200

Manassas, VA 20110

Includes copyrighted material of the National Council on Compensation Insurance, Inc. with their permission.

WC 00 00 01A (Ed 05 88)

Insurer: Key Risk Insurance Company Issued: 06/11/2025

Berkley Net Underwriters | berkleynet.com Page 1 of 1

1. Named Insured and Mailing Address

The Grassxhopper, LLC

203 Sweet Ln

Rio Rico, AZ 85648

Agency Information

CRC Insurance Services, Inc. 2211193

50 California Street

STE 200

San Francisco, CA 94111

FEIN: **-***1240 Agency ID: 2211193

Risk ID: Bureau File No.:

Other workplaces not shown above: See Schedule of Locations

Entity of Insured: Limited Liability Company (LLC)

2. The policy period is from 07/01/2025 to 07/01/2026 12:01AM Standard Time at the insured’s mailing address.

3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: AZ

B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are:

Bodily Injury by Accident $1,000,000 each accident

Bodily Injury by Disease $1,000,000 policy limit

Bodily Injury by Disease $1,000,000 each employee

C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states and U.S. territories except North Dakota, Ohio, Washington, Wyoming, Puerto Rico, and the U.S. Virgin Islands, and states designated in Item 3.A. of the Information Page.

D. This policy includes these endorsements and schedules: See Schedule of Endorsements

4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating

Plans. All information required below is subject to verification and change by audit. See Schedule of Classifications

Experience Modification Total Estimated Annual Premium $13,419

Minimum Premium $1,250 Total Estimated Surcharges and Assessments -

Expense Constant $160 Total Estimated Cost $13,419

Deposit Premium $0

Interim Adjustment Period Monthly

See Signature Form of Authorized Representatives

Countersigned By

Policy

Workers Compensation and Employers Liability Insurance

Policy #: BNET662852060

Policy #:

BNET662852060

Renewal of: BNUWC0163279

Policy Information Page_WC 00 00 01 A_05/88

Cindy Lewis WC Only

WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT

WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT_WC 00 03 13_04/84

We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.)

This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.

Schedule

State Person or Organization Job Description AZ Arizona Department of Transportation

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13

(Ed. 4-84)

WC 00 03 13

(Ed. 4-84)

© 1983 National Council on Compensation Insurance.

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective 07/01/2025 Policy No. BNET662852060 Endorsement No. 1

Insured The Grassxhopper, LLC Premium $250

Insurance Company Key Risk Insurance Company

Countersigned by