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From:AshGn 8e ue Fax:(87�265-1971 To:+18137800021 Fax: +18137800021 Pege B of 7910282016 1:32 PM <br /> EXTENSION OF INFORMATION PAGE WC 00 00 01 A- ITEM 1 <br /> ARRIER: Bridgefield Employers Insurance Company AGENCY: Greene-Hazel Associates, Inc. - 2432 <br /> P.O. 8ox 988 10739 DEERWOOD PK $LVD STE 204 <br /> Lakeland, FL 33802-0988 JACKSONVILLE, FL 32256 <br /> (863f 665-6060 (9Q4)398-1234 <br /> NSURED: Raofmax Corp POLICY NUMBER: 830 - 55130 <br /> DBA: pOLICY PERIOD: 01/18/16 - Q1118/17 <br /> 4237 Salisbury Rd # 125 <br /> Jacksonville, FL 32218-8029 <br /> Other workplaces <br /> Roofmax Corp <br /> 4237 Salisbury Rd # 125 <br /> Jacksonville, FL 32216-8p29 <br /> FEDERAL ID#46-3551093 <br /> � CORPORATION <br /> � <br /> Date Prepared:01/25/16 <br /> WC 00 Od 01 A - ITEM 1 Page 1 <br />