Laserfiche WebLink
From:Ashtin Bel �e Fax:(87�26rr1971 To:+18137800021 Fax: +18137800021 Pege 7 of 7910fL82016 1:32 PM <br /> idgefield Emplaye�s <br /> Insu�ance Compa�ay� <br /> I A Member of Great American Insurance Group <br /> A Stocic Insurer•P.O.Box 988•Lakeland, FL 33802-0988 <br /> WOR ERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE <br /> Carrier de 31267 Policy number 830-55130 <br /> Item 1. lnsured RISK I.D. OOQ000000 <br /> Nam <br /> an Roofmax Corp Individual X Corporation <br /> rwai�in 4237 Salisbury Rd # 125 Partnership �Subchapter°S" <br /> Addres Jacksonville, FL 32216-8029 Other � <br /> Other orkplaces not shown ab�ve: FEIN 46-3551093 <br /> SEE EXTENSION OF INFORMATION PAGE ITEM 1 <br /> Item 2. Policy period <br /> From 01/18/16 to 07/18/17 12:01 a.m.standard time atthe address ofthe insured as stated herein. <br /> Item 3. Coverage �� <br /> A. Workers Compensation Insurance: Patt One of the policy epplies to the Workers Compensation Law of the states listed here: <br /> Florida ' �I <br /> B. Employars Liability Insurance: Part Twa of the palicy applies to wark in each srate listed in item 3.A.The limits of our liability <br /> under Part Two are. Bodily Injury by Accident $ 1,000,�00 each accident <br /> Bodily Injury by Disease $ 1,000,000 each employee � <br /> 8odily Injury by disease $ i,000,Od0 policy limit � <br /> C. Other States Insurance: Part Three of the policy applies to the states, if any,iisted here. <br /> Alabama Arkansas Georgia lndiana Kentucky Louisiana Mississippi North Carolina South Carolina ! <br /> Tennessee Texas ' <br /> D This policy includes these endorsements and schedules: <br /> S�E EXTENSION OF INFORMATION PAGE I7EM 3.D <br /> Item 4 Premium <br /> The prernium for this policy will be determined by our Manuals of Rules, Classifioations, Rates end Ra6ng Plans.All information <br /> req ired below is subject ta vedflca�on and change by audft. <br /> Premlum Basls: �te Per 5180 of Egtimated <br /> I Classifications Code No. Total Eetlmated Remuneration Annual Premium <br /> Annual Remuneratlon <br />, SEE XTENSIDN OF INFORMATION PAGE ITEM 4 <br /> Total Estimated Annual Premium $ 47,171,40 <br /> Min mumPremium$ 1..200.00 Expense Constant $ 200.00 <br /> Cou terslgned by ��� —~� Date 01125/16 <br /> 2432 Greene-Hazel Associates, Inc. <br /> jk Date Prepared;01/25/16 <br /> WC 0 00 01 A (05/88l InGutlee copyrfgM materiel of lhe National Council on Compensatlan Insurance.Usetl wilh Its perm�sioa <br /> O 1987 Natlanal Caundl on ComDensatlon Ir�surance <br />