Laserfiche WebLink
WURQS.ERS UUMYENSAT1UN AND . MYLUYERb LJAbILITX INSUKANUM YULlUX <br /> INFORMATION PAGE <br /> Insurer: PRODUCER: Agent# 1 <br /> T.H.E. Insurance Company Allied Specialty Insurance Inc. <br /> 10451 Gulf Boulevard 10451 Gulf Boulevard <br /> Treasure Island, FL 33706 Treasure Island, FL 33706 <br /> (Carrier Code: 40851) Carrier Policy #: WC089451 <br /> Carrier Prior Policy #: NEW <br /> 1. The Insured: Galaxy Fireworks, Inc. <br /> Mailing Address: 204 E Martin Luther King Jr Blvd <br /> Tampa, FL 33603 <br /> Fein: 593092878 <br /> Policy #: 900000000419008 <br /> Other workplaces not shown above: Type of Business: Corporation <br /> SEE SCHEDULE OF OPERATIONS Risk ID: <br /> 2. The policy period is from 12:01 a.m. on 11/18/2008 to 12:01 a.m. on 11/18/2009 <br /> at the insured's mailing address. <br /> 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers <br /> Compensation Law of the states listed here: <br /> FL <br /> B. Employers Liability Insurance: Part Two of the policy applies to work in each <br /> state listed in Item 3.A. The limits of our liability under Part Two are: <br /> Bodily Injury by Accident $ 1,000,000 each accident <br /> Bodily Injury by Disease $ 1,000,000 policy limit <br /> Bodily Injury by Disease $ 1.000,000 each employee <br /> C. Other States Insurance: All states except: ND, OH, WA, WV and WY <br /> D. This policy includes these endorsements and schedules: <br /> WC000000A(04 /92) WC000308(04/84) WC000402(04/84) WC000404(04/84) WC000414(07/90) <br /> WC000419(01 /01) WC000422A(09/08) WC090303(08/05) WC090403A(01/08) WC090606(10/98) <br /> 4. The premium for this policy will be determined by our Manuals of Rules, <br /> Classifications, Rates and Rating Plans. All information required below is subject <br /> to verification and change by audit. <br /> Classifications Code Premium Basis Rate Per Estimated <br /> No. Total Estimated $100 of Annual <br /> Annual Remuneration Remuneration Premium <br /> SEE SCHEDULE OF OPERATIONS <br /> Total Estimated Annual Premium $ 1,671.00 <br /> Minimum Premium $ 518.00 Expense Constant $ 200.00 <br /> WC 00 00 01 A Countersigned by -------4/Q1jildlis.3(1-- <br />