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<br />Jun 21 01 08:18a <br /> <br />p~ 1 <br /> <br />WOIkers' (;ompellHtlon end Employers Lillbirrty <br />IMUI'8I1C8 Policy <br /> <br />AmCOMP Preferred Ins. Co. Irii~I:_tJlml:?t.t:~W~.;t~mmt{f <br />p.o. Box 86806 <br />North Palm Beach. Fl 33408-8806 WCV 70 1 65 62 I 0 5 / 1 1 12 0 0 1 0 5/ 1 1 /2 0 02 <br /> ~.~... Ill... addIu. "'!he <br />::::;::::::;:::;;::;;::;:;;;;(j:/:?::::::::;::\:<:\::::::::::~;:;X:;::::i:::/:.::;.::::::::::::::::;:;;:'~::::-:'::::::::::::":~.:::\'::::-::::~:::.::::;::::::::::::;i\:::?:::~.?li'iiri_clloif:::::::>::'::::.:~:::::::;:::~:::~::;:.:;::;;::::::::::::::,~:.:;:::::::;::::::::::::;:.:.:'::::':~~::::~:/?::::::?:~::::::::;:::.::\:;:::::'::::::~::;7;\.;:::,;:::;D:.::::;:::;:;/::;;;::.:;~ <br />RENEWAL DECLARATION <br />.:.:::>:.:};:::::::~:::J.:{:::...:......:.,:...:,.......:,:.....:...:.:.....:....:...:......-:........-::t:::::::>:::::/f;/;::::it:::.::?::,y:::'.::::(:::;:::::::::/ ::/::;::::t:.::::::Y::\:}::;::;};::::~::.:;::::::.~:::::::;::::::::::::::::::;;:::.:tAM;:.::;?::::.:::.:::~:/::::::::/::,:::t:.:\:::/:~:::?:::;;;:::..::::;::;:t?:~~::::::::. <br /> DAVIS CONTRACTING INC AND crc DIBIA CICORP-USI , INC . 02 58 0 10 <br /> SOUTHERN INDUSTRIAL LUBRICANTS 4 02 S KENTUCKY AVE , STE 46 0 <br /> 3 782 6 SKYRIOOE CIRCLE p 0 DRAWER 1 3 9 8 <br /> DADE CITY FL 33 525 LAKELAND . FL 3 3 8 02 - 13 9 8 <br /> Telephone: ( 8 0 0 ) 27 7 5 1 85 <br />Customer II I Carrier # I FEIN II I Risk 10 II I Entity 0' Insu~ <br /> 3 1283 5 9 2576242 0 9 5 0 54 528 CORPORATION <br /> <br />Additional Locations: <br /> <br />2. The Policy Period is from 05/11/2001 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 pofley 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 liability under Part TWO are: <br /> <br />Bodily Injury by Accident $ 100. 000 each accident <br />Bodily Injury by Disease $ 50 0 , 000 policy limit <br />Bodily Injury by Disease $ 100, 000 each employee <br /> <br />C. Other States Insurance: Part THREE of the policy applies 10 the states, if any, listed here: <br />Aft 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 win be determined by our 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 />200 <br />-317 <br /> <br />Assessments and Taxes $ <br /> <br />o This is a Three Year FIXed Rate Policy <br />Premium Adjustment Period: !XI Annual; 0 Semiannual; 0 Quarterly; 0 Monthly <br /> <br />Total Estimated AnnualPremium $ $7, 820 <br /> <br />Countersigned this Day of <br />Issued Date: 05/14/01 <br /> <br />Issuing Office AmCOMP Preferred Ins. Co. <br /> <br />Authorized Representative <br /> <br />WC990629 (5/98) <br /> <br />INSURED <br />