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<br />Jun 2101 08:18a <br /> <br />WorIIers' (;ompenntion end Emp/oyers LiDbirtty <br />In8lhnl:8 Policy <br /> <br />p. 1 <br /> <br />AmCOMP Preferred Ins. Co. i@i:[~f.ii_mI@rRi.tg&._&~~;}1Mi& <br />P.o. Box 88806 <br />North Palm Beach. A.. 33408-8806 wcv 7 0 16 562 I 0 5 1 1 1 1 2 001 05/ 1 1 /2 002 <br /> w.:-~... at "'" adcIlwca "'... <br />";"""""';c",,,;;,,,,,,,,;c,";S";;'f'U""""''''2'''':''';i;''''';''';;''''~;';,f'':';;'%;'"'';''''''"'''C''''>';'''''''''''''''''ii'''.'1/,,,;;;,,,<,,;,,';; <br />RENEwAL DECLARATION <br /> . . '.... u", . _ _". .... ::;:;:::;t~:,:~:;'.:t~~~;:~~;;~:;~~;~;:::~i:;.:}:.:.:;;~:;:::~;::X~;;::t{t~@i~tt~t:~.:?::F:E':;:(;:;;:}::;;:::::;::;~:~:;:~;i~:/:~;;tW;:':'::; <br />., ,..q'~1:;';;;- '" . '.. '. .h. UU.h........._U.....h..U.............._ <br />. .....-......., _.h. . ." ~.. -..". ..... .~-,. _.h" _.. ... n..... ._,. ...... ..__. <br />.~.:-:.:.:.:.:.:.:.:.:.:...::.:-:-:...::.:...................~..................:... . ..........._.~-.... ..~.. .-..... ..... ...--.... ..... <br /> . .................................................... <br />.................................................................................. <br /> DAVIS CONTRACTING INC AND CIC D/B/A CICORP-USI , INC 0258 0 10 <br /> SOUTHERN INDUSTRIAL LUBRICANTS 4 02 S . KENTuCKY AVE , STE 4 6 0 <br /> 3 7826 SKYRIDGE CIRCLE P 0 DRAWER 1 3 I} 8 <br /> DADE CITY FL 3 3 52 5 LAKELANo, FL 3 3 8 02 -13 98 <br /> Telephone: ( 80 0 ) 277 5185 <br />Customer II 1 Carrier II T FEIN #I 1 Risk 10 , I Entity of In8uI8d <br /> 3 1283 592 576242 0 95054 528 CORPORATION <br /> <br />Additional Locations: <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 />3. A. Workers' Compensation Insurance: Part ONE of the parlCy 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 Injwy by Disease $ 500,000 policy limit <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 />AU slates EXCEPT monopolistic states. <br /> <br />O. This policy inclUdes these endorsements and schedules: See attached s;hedule. <br /> <br />4. The premium for this policy will 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 />Total estimated AnnualPremlum $ $7,820 <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: lXJ Annual; 0 Semiannual; 0 Quarterly; 0 Monthly <br /> <br />Countersigned this Day of <br />Issued Date: 05/14/01 <br />Issuing Office AJncoMP Preferred Ins. Co. <br /> <br />Authorized Representative <br /> <br />WC990629 (5/98) <br /> <br />INSURED <br />