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06/23/2016 01:03PM 7278190905 FATRIOTICFIREWORKS PAGE 02/02 <br /> ' � ° � � RECEI'�i�D 96123/2916 12:2EPh� 7279190905 PATRIOTZCFIREWDRKS <br /> �- •06l2?/2�16 12:'�5F�rv1 31�38105�m PaTpIOTiC PAGE 02�a5 <br /> �A `IORI?hWOdKE(LS�CONPEI�S'�TrJn �yp�x��{5 COMPENSA'f�oN <br /> �cr•;�ueE��r��soc�T�oN.i��c At�iD <br /> EMPLOYERS L�Ag�LITY POLICIP <br /> • iP�FORNIAT�ON PADE WC 04 00 01 ( A) <br /> , �,�L���e���gEp, (BFRI3UB—?D7666c}-7-16) <br /> .RENEk1AL OF (6FR1�U9-7�76664-7-15) <br /> ifd�i����: ��-t�Pd�AW.�. JUA NCC�CO�OD�: 80179 '� <br /> 9. <br /> P�4DiJC�R: <br /> i�Sil�$�D; SRITTOf� GAI.I,AGHER <br /> p�,�IOTIC FIR�W��KS �NC & y37� E 9TF! ST 3�TH F1�DOR <br /> .����{ �, �{��H SCNOOf. ROAD ��EU��AND OH �44114 <br /> I�IDIAN,A�ALSS bN �6241 . <br /> insured i�a A MII�.TXPL� s7ATu5 <br /> �S�.nar wvrk�l�oas gnd ldentifieatlon numbera are snown In the sci�edule(�)ee�ached. <br /> .�, Tf1� po�lcy periotlls from 05-i e�i 6 to os-•�5-17 12:a1 A.M, at tha insured'a ma.11ing addres9. <br /> ,, q, �,����,��,R�COtu1PE13SA7sO�'�tdSURA�1��: ��ti'�dn$of the polioy applte9 to the Workers <br /> CompsnsaBlon L.aw�f�he state(s) klsted hsre: <br /> ' FL <br /> � o� <br /> i �� <br /> '� g, ��;p�.q�yERS�.fAOtLlY1f 1NSU4�4I��E- °a�t��`No of the poll�y applles Lo work In each state Il�t�d ln <br /> ; �, <br /> { �� ' ��m,3,p. ���a�imits o�our liak�llity ynd�r Part 1'wo afe; <br /> ' m�-°°"' �4M�ly Inju�y by�ocfdent: � 6UOb00 Each Accid�nt <br /> � � ' Bodlly In)ury by Dissase; � 5000ao Policy 'Ltmit <br /> ' '= Bod(ly Inju�y bY Diseaee: � 500000 Eacf���p�aY�e <br /> �.� I�ea to the s�aies,tt any,iPsted here: <br /> _� �;. Gz�i����'A�'��tt�Sl34�A���: Part Th�e��4 tre poilcy aPA� <br /> °e �F� E(VDORSE.MEN�' �WGJUF� 0� Oi <br /> — , <br /> � <br /> � <br /> .� � <br /> � <br /> ^� s�, This�oyioy i�cludes thAae�ndurs���-�snts and schedules: <br /> ��= SEE L2S'iTIYG 0� E�lDORS��lEN7S � EXT�NS�LON flF INFO PAG� <br /> a M"� ' <br /> �� <br /> �� �. The premium fiorthis poliaS�wil�be deee�mtn�d by our Manual o�Ruls�, Classtfications, Rates an�d R�ting <br /> �� �'t?ns, A1f c�qu�red informstlnn is s�t�j�ct#�Verifi�a`c�on and change by audi�. ANE�tt1A�L.Y. <br /> • �� <br /> , ST ASSIG�: FL <br /> � ��T��r i�sua: o�-a6-9� wc <br /> �Ft���: FE.�exD� �vc J13A $''-� 29Kto,j Page 1 oF 1 <br /> ���P�iB�"�'�R: SRITI'Q� G.AL►{+�Fi�R� <br /> :;:aoa a <br />