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<br />Jun 21 01 08:18a <br /> <br />p. 1 <br /> <br />Workers' t:ompenae1lon end Employers LiobiIity <br />lne.....ce Policy <br /> <br />AmCOMP Preferred Ins. Co. ;:m.if~l~fl!1mr.@Mi&.~ti~~~l~tJnEK.:{;ir <br />P.o. Box 88806 <br />North Palm Beach, Fl 33408-8806 WCV 70 1 65 62 I 0 5 I 11 1 2 0 01 05 I 1 1 12 0 02 <br /> ~=-~... 11th acIdMo. 01 !he <br />:\?/::::;'/::;::::;:\}::/:::::::::::::')):::::::::::::::::::::~:::::;::~:\:~.:\::/:::::::::-:::::~:~~:'~::':-:::;;:::::::':~.::::::+:'::::~::~:::;:::::;::::}::::::::/::::~.?r.ijii_dlOii::::YE:~~:/:;~::}::;:~:.::\\::::::::;:;:~~::~:;~~::::~;:;.:::~:~~::::~::::~:.:::::::;::~:::::::::::::::r!:~:.:(::::(;.::::.;:.\;::~:.:~,n::::::~:V::::;T::;~~:;::::: <br />RENEWAL DECLARATION <br />...........::1:... . " .....,.. , ................................................. :.::::~;:::??~::::::y::::.~/:::::/}::;:{.;:}::.:.:;::::::::::::::/..::::;/::~~;::::j:;::::!.:.)::::::::::::;:::::...::::?:.:.:\;/::;::.:i:::::::::::!:':~:::t\::::::::::;;. <br />::::::.:::~::::.~::::::::::~::::::::_,~:::::.. ..... -.. mh...::...,....,....._ ....::... -..... /.... _.._. ..:... .......:::::::::::::::..:::::::::~~::~:::::::::::::::::X::::::~:~:::::::.:::::::::::X::::::::::::::: <br /> OAVr S CONTRACTING INC AND CIC D/B/A CICORP-US I , INC 02 58 0 10 <br /> SOUTHERN INDUSTRIAL LUBRICANTS 4 02 s KENTUCKY AVE , STE 4 6 0 <br /> 3 782 6 SKYRIDGE C IRCLE P 0 DRAWER 1 3 98 <br /> DADE CITY FL 3 3 525 LAKELAND, FL 3 3 8 0 2 - 13 9 8 <br /> Telephone: ( 8 0 0 ) 277 5 185 <br />Customer' I Carrier' I FEIN II I Riaft ID , I Enlily 0' InsulWd <br /> 3 1283 5 92576242 0 9 5 0 54 52 8 CORPORATION <br /> <br />Additional Locations: <br /> <br />2. The Policy Period is from 05/1112001 to 05/11/2002 12:01 a.m. Standard Time at the Insured's mailing address. <br /> <br />3. A. Workers' Compensation Insurance: Part ONE of the policy applies to the Workers' Compensation law of the states <br />listed here: Florida <br /> <br />B, Employers Liability Insurance: Part TWO of the policy applies to work in each state listed in Item 3A. <br />The limits of our liabirdy under Part TWO are: <br /> <br />Bodily Injury by Accident $ 100, 000 each accident <br />Boady Injury by Disease $ 500 , 000 policy limit <br />Boc:iIy Injury by Disease $ 100 , 00 0 each employee <br /> <br />C. Other States Insurance: Part THREE of the policy applies to the states, if any, listed here: <br />AU states EXCEPT monopolistic states. <br /> <br />D. This policy includes these endorsements and SChedules: See attached schedule. <br /> <br />4. The premium for this policy wit be determined by oW" Manuals of Rules, Classifications, Rates, and Rating Plans. <br />All information required below is subject to verifICation and change by audit. <br /> <br />SEE EXTENSION OF INFORMATION PAGE <br /> <br />Minimum Premium $ <br /> <br />750 <br /> <br />Expense Constant $ <br />Premium Discount $ <br /> <br />Total Estimated Ann....Premlum $ $7,820 <br /> <br />200 <br />-317 <br /> <br />ASS8S8R1ents and Taxes $ <br /> <br />o This is a Three Year FIXed Rate Policy <br />Premium Adjustment Period: IX) Annual; 0 Semiannual; 0 Quarterly; 0 Monthly <br /> <br />Countersigned this Day of <br /> <br />Issued Date: 05/14/01 <br /> <br />Issuing Office AmCOMP Preferred Ins. Co. <br /> <br />Authorized Representative <br /> <br />WC990629 (5/9B) <br /> <br />INSURED <br />