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i <br /> From:Ashtin Begoe Fax:(87�26''r1971 To:+18137800021 Fax: +18137800021 Pege 33of 79102820161:32 PM <br /> , <br /> 'dge,f�eld �inploye�s <br /> Insuranee Campany� <br /> A Member af Great American Insurance Group <br /> A Stock Insurer•PO.Box 988•Lakeland,FL 33802-0988 <br /> WOR ERS COMPENSATION AND EMPLOYERS LIABILfTY INSURANCE POLICY INFORMATION PAGE <br /> Carrier de 31267 Policy number 830-55130 <br /> Item 1. Insured <br />, R�sK�.o. o00000000 <br /> Nam <br /> an Roofmax Corp Indiv�dua� X Corporation <br />, Mailin 4237 Salisbury Rd # 125 Partnership Subchapter"S" <br /> Addres Jacksonville, FL 32216-8029 ` — <br /> �ther <br /> Other orkplaces not shown ebove: FEIN 46-3551093 <br /> SEE EXTENSION OF INFORMATION PAGE ITEM 1 <br /> Item 2. Policy period <br /> From 07/18/16 to 0���8�17 12:01 a.m.standard time at the address of the insured as stated herein. <br /> Item 3. Ccverage <br /> A. Worlcers Corripensetion Insurance: Part One of tite palicy applies to the Workers Compensetion Law of the states listed here: <br /> Florida <br /> B Employers Lfabifity Insuranoe: Part Two of the policy applies to work in each state listed in Item 3.A.The limits of our liability <br /> under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident <br /> Bodlly Injury by Disease $ 1,000,000 each employes <br /> Bodily Injury by Disease $ 1,�OO,U00 policy limit <br /> C. Ofher 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 endarsements and schedules: <br /> SEE EXTENSION OF INFORMATION PAGE ITEM 3.D <br /> Item 4' Premium <br /> The premium far this palicy will be determined by our Manuals of Rules, Classiflcations, Rates and Reting Plans.All informafian <br /> req Ired below is subject to�erification and change by audft. <br /> Glassifications Premlum Basis: Rate Per y100 of Es6mated <br /> Code No. Total FsUmated Remuneration Annual Pr+emlum <br /> Annual Remunefatlon - <br /> SEE XTENSION OF INFORMATION PAGE ITEM 4 <br /> i Total Estimated Annual Premium $ 47.���•� <br /> Min mumPremium$ 1,200.00 Expense Constant $ 200.00 <br /> Cou tersigned by w� Date �1/2511fi I� <br /> 2432 Greene-Hazel Associates, Inc. <br /> jk Date Prepared:01/25116 <br /> WC 00 01 A {Ob/86l I�ludes copyright matedalof the Natlonal Councfl on Campensation Insurance.Used wlth Ite pertnfaeion. <br /> �1887 Natlonal Councll on ComPensetlon Insurance <br />