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From:Ashbn Be ue Fax:(87�265-1971 To:+18137800021 Fax: +18137800021 Page 9 of 7910282Di 61:32 PM 'i <br /> EX7ENSION OF INFORMATION PAGE WC 00 00 01 A- ITEM 3.D <br /> CARRIER: Bridgefield Employers Insuranae Company AGEI1lCY: Greene-Hazel Associates, Inc, - 2432 <br /> � P.O. Box 988 90739 QEERWO�D PK BLVQ STE Z00 <br /> Lakeland, FL 33802-0988 JACKSONVILLE, FL 32256 <br /> i863?665-6060 (904)388-1234 �� <br /> I INSURED: Roofmax Corp POLICY NUMBER: 830 - 55130 <br />, DBA: E OD• / - 817 <br /> POLlCY P Rl . �1198 16 0111 ! <br /> 4237 Salisbury Rd # 125 <br /> Jacksonville, FL 32216-8029 <br /> Schedule of Endorsements <br /> Form Number: Edition: Description: <br /> � WC 00 03 08 0484 Partners. Officers and Others Exciusion Endt <br /> WC 00 03 10 d484 Sole Proprietors, Partners, Officers, Others Cover <br /> WC 00 04 04 04-84 Pending Rate Change Endt <br /> WC 00 04 06 A 0$-95 Premium Discount Endt <br /> WC 00 04 14 07-9U Noti�cation of Change in Ownership Endt <br /> WC OU 04 19 01-01 Premium Due Date Endt <br /> WC 09 04 01 06-87 FL Contracting Classification Premium Adjustment E <br /> WC 09 �4 02 10-88 FL Experience Rating Modification Factor Endt <br /> WC 09 �4 03 B 01-15 FL Terrorism Risk Ins. ProBrem Reauthorization Act <br /> WC 09 04 07 07-13 FL Non-Cooperation with Premium Audit Endt ' <br /> WC 09 06 06 1 Q-98 FL Employment and Wage Information Release Endt <br /> WC 99 03 03 1 1-1 1 Employers Liability Coverage Endt <br /> WC 99 06 01 05-06 FL Legal Action/Collection Endt <br /> WC 99 06 06 10-10 Florida Participating Endt <br /> I <br /> � <br /> Date i'repared: 01/25/16 <br /> WC 00 �0 01 A - ITEM 3.D Page 1 <br />