SELF-INSURED GROUP ROSTER 10/19/2018 Note: The first …

1 SELF-INSURED GROUP ROSTER06/15/2018 Note: The first digit in the Certificate Box represents Administered or self AdministeredSelf Administered and Administered is (1) self Administered is (2) Administered is (3)5star SpecialtyRps MonumentAvi Risk ServicesSelf insured SolutionsAffinity GROUP Administrators33333 Jeffrey J. BattaglieseGreg S. FamousTravis HarperGene Axtell101 West Ave, Ste 150255 Great Valley Parkway, Ste 200985 Old Eagle School Rd, Ste 504430 N. Vineyard Ave, # Box 713845004501450245034504(267)289-1776 (610)647-4466 (610)975-6053 (800)592-0047 (916)550-9489 Jenkintown, PA 19046 Malvern, PA 19355 Wayne, PA 19087 Ontario, CA 91764 Folsom, CA 95763 NAICS Code: 55 NAICS Code: 62 NAICS Code: 48 NAICS Code: 23 NAICS Code: 44 TPATPATPATPATPA316-02316-03048-01011-053 34-01 Corvel Enterprise Comp, Inc. - Rancho CucamongaCorvel Enterprise Comp, Inc.

2 - San DiegoAthens Administrators - ConcordSedgwick Claims Management Services, Inc. - OrangeAmerican Claims Management, Inc. - San DiegoMembersMembersMembersMembersMembers Auto Dealers Compensation Of California, , Truckers Safety Association Workers Compensation Program, Contractors Network, Auto Dealers self -Insurance Program, Effective Date: 01/01/2013 Revoke Effective Date: 03/01/200901/01/200202/27/200305/01/2003 06/16/200309/12/2003 Cert Effective Date: Cert Effective Date: Cert Effective Date: Cert Effective Date: Cert Effective Date: Rps MonumentAffinity GROUP AdministratorsAffinity GROUP AdministratorsAuxiliary Organizations Workers' Compensation Plan, Distributors Of California SELF-INSURED GROUP , BattaglieseGene AxtellGene AxtellRob LeongGene Axtell255 Great Valley Parkway, Ste Box Box 7138c/o Alliant Insurance Servicesc/o Affinity GROUP Administrators45064507450845094510(610)6 47-4466 (916)550-9489 (916)550-9489 Malvern, PA 19355 Folsom, CA 95763 Folsom, CA 95763 San Francisco, CA 94111-2711 NAICS Code: 71 NAICS Code: 32 NAICS Code: 52 NAICS Code: 81 TPATPATPATPA128-17048-01128-17146-05011- 23 Matrix Absence Management, Inc.

3 - RosevilleAthens Administrators - ConcordMatrix Absence Management, Inc. - RosevilleAcclamation Insurance Management Services - SacramentoSedgwick Claims Management Services, Inc. - Rancho Cordova600 Montgomery St Ste 900 MembersMembersMembersMembersMembersElite Golf Club Program, Manufacturers self Insurance Program, Union self insured GROUP Of California, IncorporatedAuxiliary Organizations Workers' Compensation Plan, Distributors Of California SELF-INSURED GROUP , Effective Date: 01/01/2007 Revoke Effective Date: 01/01/2005 Revoke Effective Date: 01/01/201101/01/200401/01/200402/01/2004 03/01/200404/15/2004 Cert Effective Date: Cert Effective Date: Cert Effective Date: Cert Effective Date: Cert Effective Date: Rps MonumentNonprofits' UnitedRps MonumentRps BattaglieseIrene Battagliese255 Great Valley Parkway, Ste 200610 Fulton Ave, Ste 200255 Great Valley Parkway, Ste 200255 Great Valley Parkway, Ste 20045114513451445154516(916)983-3387 (610)647-4466 (916)868-6228 (610)647-4466 (610)647-4466 Folsom, CA 95763-7138 Malvern, PA 19355 SACRAMENTO, CA 95825 Malvern, PA 19355malvern, PA 19355 NAICS Code: 42 NAICS Code: 62 NAICS Code: 62 NAICS Code: 61 NAICS Code: 62 TPATPATPATPATPA048-01132-13048-01048-01 Athens Administrators - ConcordYork Risk Services GROUP , Inc.

4 - RiversideAthens Administrators - ConcordAthens Administrators - Box 7138 MembersMembersMembersMembersCornerstone Comp, ' United Workers' Compensation GROUP , Private Schools Workers' Compensation self -Insurance GROUP , Comp, Effective Date: Cert Effective Date: Cert Effective Date: Cert Effective Date: Cert Effective Date: self insured SolutionsSelf insured SolutionsAffinity GROUP AdministratorsAuto Dealer Access, Monument3333 Travis HarperTravis HarperGene AxtellMichael W. Battagliese430 N. Vineyard Ave, #102430 N. Vineyard Ave, # Box 71382500 Via Cabrillo Marina255 Great Valley Parkway, Ste 2004517451845194520(800)592-0047 (800)592-0047 (916)550-9489 (310)832-8900 (610)647-4466 Ontario, CA 91764 Ontario, CA 91764 Folsom, CA 95763 San Pedro, CA 90731-7224 Malvern, PA 19355 NAICS Code: 11 NAICS Code: 44 NAICS Code: 52 NAICS Code: NAICS Code: 62 TPATPATPATPATPA239-07334-01128-17048-01 Intercare Holdings Insurance Services, Inc.

5 - FresnoAmerican Claims Management, Inc. - San DiegoMatrix Absence Management, Inc. - RosevilleAthens Administrators - ConcordMembersMembersMembersMembersMembe rsCalifornia Agricultural Network, Restaurant Mutual Benefit CorporationWestern Independent Bankers self Insurance Program Of CaliforniaAuto Dealer Access, Comp, Effective Date: 07/22/2010 Revoke Effective Date: 03/13/200512/01/200403/01/200503/16/2005 07/01/2005 Cert Effective Date: Cert Effective Date: Cert Effective Date: Cert Effective Date: self insured SolutionsAmtrust North America, Risk Services, LlcFinish Line self Insurance GROUP , insured Solutions333333 Travis HarperStephen UngarGreg FamousG. Michael LyonTravis Harper430 N. Vineyard Ave, #102101 California Street, 22nd Floor985 Old Eagle School Rd, Ste 5044961 Katella Ave430 N. Vineyard Ave, #102452145224523452445254526(800)592-004 7 (610)975-6053 (714)820-2743 (800)592-0047 Ontario, CA 91764 San Francisco, CA 94111 Wayne, PA 19087 Los Alamitos, CA 90720 Ontario, CA 91764 NAICS Code: 11 NAICS Code: 31 NAICS Code: 33 NAICS Code: 71 NAICS Code: 11 TPATPATPATPATPA239-07092-6099-01152-10 Intercare Holdings Insurance Services, Inc.

6 - FresnoAdminsure, Inc. - OntarioFinish Line self Insurance GROUP , Inc. - Los AlamitosLwp Claims Solutions, Inc. - SacramentoMembersMembersMembersMembersMe mbersCalifornia Farm Management, And Independent Producers self Insurance Program Of CaliforniaFabricated Metal Products Of California Workers' Compensation GROUP , Line self Insurance GROUP , Agricultural Products, Effective Date: 12/01/2008 Revoke Effective Date: 04/01/200908/01/200508/01/200509/13/2005 07/01/200512/01/200512/01/2005 Cert Effective Date: Cert Effective Date: Cert Effective Date: Cert Effective Date: Cert Effective Date: Cert Effective Date: self insured SolutionsAvi Risk ServicesSelf insured SolutionsAvi Risk ServicesKeenan & Associates3333 Travis HarperGreg S. FamousTravis HarperGreg S. FamousLisa A. Overholt430 N. Vineyard Ave, #102985 Old Eagle School Rd, Suitr 504430 N. Vineyard Ave, #102985 Old Eagle School Rd, Ste 5042355 Crenshaw Blvd.

7 , #2004527452845294530(800)592-0047 (610)975-6053 (800)592-0047 (610)975-6053 (310)212-0363 Ontario, CA 91764 Wayne, PA 19087 Ontario, CA 91764 Wayne, PA 19087 Torrance, CA 90501 NAICS Code: 44 NAICS Code: 31 NAICS Code: 11 NAICS Code: 44 NAICS Code: 62 TPATPATPATPATPA048-01011-05239-07152-101 32-11 Athens Administrators - ConcordSedgwick Claims Management Services, Inc. - OrangeIntercare Holdings Insurance Services, Inc. - FresnoLwp Claims Solutions, Inc. - SacramentoYork Risk Services GROUP , Inc. - OrangeMembersMembersMembersMembersMember sHousehold Industries SELF-INSURED GroupFood Products Of California Workers Compensation Program, Livestock Producers, California Auto Dealers self -Insurance GROUP , Affiliated Groups Insurance Of CaliforniaActiveActiveActiveActive01/01/ 200601/01/200607/01/200701/01/2008 Cert Effective Date: Cert Effective Date: Cert Effective Date: Cert Effective Date: Avi Risk ServicesSelf insured SolutionsSig Solutions333 Greg S.

8 FamousTravis HarperMichael Lyon985 Old Eagle School Rd, Ste 504430 N. Vineyard Ave, #1024961 Katella Ave453145324533(610)975-6053 (800)592-0047 (714)820-2786 Wayne, PA 19087 Ontario, CA 91764 Los Alamitos, CA 90720 NAICS Code: 72 NAICS Code: 62 NAICS Code: TPATPATPA011-05239-06358-01 Sedgwick Claims Management Services, Inc. - OrangeIntercare Holdings Insurance Services, Inc. - GlendaleFinish Line self Insurance GROUP , Inc - Los AlamitosMembersMembersMembersEntertainme nt Employees Workers Comp Program, Healthcare Industry ProgramPost Time self Insurance GroupActiveActiveActive02/01/200804/05/2 01307/01/2017 Cert Effective Date: Cert Effective Date: Cert Effective Date.