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Apr 22 2009 12:40PM HP LASERJET FAX p.3 <br /> WO1UU KS U'I,iNZXNSATLUN AND ZtL' VXJSKti LlAB L.Tr 11VSU1(ANU]S rUL1UX <br /> INFORMATION PAGE <br /> 5 <br /> Insurer: PRODUCER: Agent# \ 1 <br /> T.H.B. Insurance Company / Allied Specialty Insurance Inc. <br /> 10451 Gulf Boulevard 10451 Gulf Boulevard <br /> Treasure Island. FL 33706 Treasure Island. FL 3706 <br /> (Carrier Code: 40851) _ Carrier Policy #: WC08945 <br /> Carr r Prior Policy #: NEW <br /> 1. The Insured: Galaxy Fireworks. In . <br /> Mailing Addrees: 204 E Martin Luther ,*ing Jr Blvd /' <br /> Tampa. FL 33603 <br /> Fein: 593092878 <br /> Policy #: 9''- <br /> Other workplaces not own above: Type of Business- 'rpora i•n <br /> SEE SCHEDULE OF OPERATIONS Risk +4: <br /> 1 <br /> 2. The policy period is from 12:01 a.m. on 11/18/2008 to 12:01 a.T. on 1 1: 0 <br /> at the insured's mailing address. <br /> 3. A. Workers Compensation Insurance: Part One of the policy appli to the Work -rs <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 No 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 /> Minim= Premium $ 518.00 Expense Constant $ 200.00 <br /> WC 00 00 01 A Countersigned by v <br />