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<br />l_...._>.~..'.............,.,~'..~.~-'.~~__l.3';::-.,;r:;o'""""~~~-:.~',""-,=.".,~_ <br /> <br />.;. <br /> <br />.AR <br />~ <br /> <br />WCIP <br /> <br />'Ii' <br />'-::' <br />'r <br /> <br />~"~ <br /> <br />ACCOl;:\T :\0, <br />49 05 61 <br />POLICY :--00. <br /> <br />seD ACCT !'O, <br />0000 <br /> <br />LIBER1Yfe <br /> <br />MUTUALW <br /> <br />. Liberty ':\ lutuallnsurance GroupfBoston <br />LIBERTY MUTUAL INSURANCE COMPANY 15628 <br />SALES OFFICE' CODE SALES REPRESE:--OTATIVE <br /> <br />Workers Compensation and <br />Employers Liability Policy <br /> <br />.. <br /> <br />~ <br /> <br />ISSUING OFFICE 570 <br />INFORMATION PAGE <br /> <br />TO,CO <br /> <br />CODE :-.; <br /> <br />1ST YEAR <br /> <br />CI-351-490561-01091/9TAMPA 555 ASSIGNED <br /> <br />I~m 1,~ameofCARLYLE R. HUFFMAN DOING BUSINESS AS <br />Insured CARL YLE ELECTR I C <br />P.O. BOX 251 <br />Addre~ CRYSTAL SPRINGS, FL 33524 <br /> <br />000 2 89 <br /> <br />FEIN 592792170 <br /> <br />Status <br /> <br />INDIVIDUAL <br /> <br />Other workplaces not shown above: S E P H Y R H ILL S : <br /> <br />38300 11TH AVENUE <br /> <br />Item 2, Policy Period: From <br />\' <br /> <br />Mo, DIY V.., <br />05 30 90 <br />12:01 AM <br /> <br />to ~5 ~"~ ;ei ---~) <br />..standai.itrtme:,at=~f the insured as' stated hcrein, <br /> <br />Item 3, Coverage <br /> <br />A, Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states <br />listed here: ' <br />FL <br /> <br />B. Employers Liability Insurance: Part Two of the policy applies to work in each state li~ted in item ),A. The limits <br />of our liability under Part Two are: ' " , <br />Bodily Injury by Accident $ 100 ,000 each accident <br />Bodily Injury by Disease $ 500 , 000 policy IJmit <br />Bodily Injury by Disease $ 100 , 000 each employee <br /> <br />C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: <br />ALL STATES EXCEPT THOSE LISTED IN ITEM 3A AND THE STATES OF <br />NV NO OH WA WV WY AK <br /> <br />D, This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE <br /> <br />Item 4, Premium - The premium for this policy will be dctennined by our Manuals of Rules. Classifications. Rates <br />and Rating Plans, AU information required below is subject to verification and change by audit. <br /> <br />! <br />I <br />I <br />I, <br /> <br /> P,emium Basir Rates L1:'\E 1 1 <br /> Estimated Per 5100 E~tlm'ted <br /> , Code TOIlI Annuli or Re' "nnual <br /> Classifications , :-;0, Remuntrltion muneruion l'r~mtums <br />SEE EXTENSION OF INFORMATION PAGE <br /> <br />o <br /> <br />k <br />, I <br />i <br />, <br /> <br />\linimum Premium $ 550 <br /> <br />( FL> <br /> <br />Total Fstirnated Annual Premium $ <br /> <br />1,013 <br /> <br />Interim nlljustment or premium shall be made: ^ N N U A L ~ V <br />*N*9NOO* <br /> <br />.. , <br /> <br />ARC <br /> <br />Deposit Premium $ <br />81 <br /> <br />1 ,013 <br /> <br />This policy, including all endorsements isslIed therewith. is hereby cOllntersigned by <br /> <br />.\uthlln;pd Rtple~Phl.'u\.'e <br /> <br />1 lale II: II~ '111 <br /> <br />PRODUCER OF RECORD <br />INSURANCE MART <br />37606 CtRt S4 Wt <br />ZEPHVRHILLS, Fl ,34249 <br /> <br />I.oc, C;,,'I Term. Ope" TN <br />1 2/02/90 <br /> <br /> <br />RENEWAL OF <br />WC1-351-490561-019 <br /> <br />I: <br /> <br />GPO JOJO RI <br /> <br />\IT 00 00 01 ,\ <br /> <br />COPYright 1987 National CounCil on Comr~n~atlon Insurance <br />