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<br />Jun 21 01 08:18a <br /> <br />worrcere' Cornpel1lltltlon 8I1d Employers LilIbiIity <br />lnelhnce PoHcy <br /> <br />p.l <br /> <br />AmCOMP Preferred Ins. Co. ;mIHi.:MtJM@i:M&W_i%Ii:.Mf <br />P,O. Box 88806 <br />North Palm Beach. Fl 33408-8806 WCV 70 16562 I 05 / 1 1 / 2 0 01 05/ 1 1 /2 002 <br /> ~~... III the addle.. d !he <br /> <br />RENEwAL DECLARATION <br />.:',:::.:::'::/::::::;:.:::1~::::::' ":;" . " ::" '. ':;' .' . '.:,;:::c/:\::::~::~:~:;:::t~:0:;::::;:;;:::,\:~,:::::~:::;::::::::::. ::\::?I~(~:~::tfH};~:;::::~':~::?~~.:>.T\\;::::;\~~~~~:?tf.~:'::~:~);:~:;::::(:::{':::::::::::~::;:,;~:i:i:;i::i;;~~'::;::::;::::::::;:::) <br />..'....................--..-...................................-..'...........-...........................................-.................-- ... <br /> DAVI S CONTRACTING INC AND crc D/B/A CICORP-usr , INC . 02 58 0 10 <br /> SOUTHERN INDUSTRIAL LUBRICANTs 4 02 S KENTUCKY AVE , STE 460 <br /> 3 782 6 SKYRIDGE CIRCLE P 0 DRAWER 1 3 98 <br /> DADE CITY FL 3 3 525 LAKELAND, FL 3 3 8 02 -13 98 <br /> Telephone: ( 8 0 0 ) 2775185 <br />Customer # I Carrier. I FEIN II 1 Rist 10 , I Entity 0' IneuI8d <br /> 3 1283 592 576242 0 95 054 528 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 poficy 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 fimits of our liability under Part TWO are: <br /> <br />Bodily Injury by Accident $ 100 , 000 each accident <br />Bodily 'njwy 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 to 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 tor this policy Will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans. <br />All information l'9Quired befow 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 Estirn8ted AMualPremlum $ $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: !XI Annual; 0 Semiannual; 0 Ouarterly; 0 Monthly <br /> <br />Countersigned this Day of <br />ISSUed Date: 05/14/01 <br /> <br />Issuing Office AmcoMP Preferred Ins. Co. <br /> <br />Authorized Aepresentmive <br /> <br />WC990629 (5/98) <br /> <br />INSURED <br />