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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br /> INFORMATION PAGE <br /> NEW AEQUICAP INSURANCE COMPANY <br /> Renewal of Number <br /> 3000 WEST CYPRESS CREEK ROAD <br /> FORT LAUDERDALE, FL 33309 Carrier Code: 25477 <br /> FEIN: 59- 2581466 <br /> Policy No. WC07075488 RISK ID # NONE <br /> 1. The Insured/Mailing address: <br /> ® Individual 0 Partnership <br /> RONALD J. VICKERY <br /> 37912 7TH AVENUE ❑ Corporation or <br /> ZEPHYRHILLS, FL 33542 FEIN # 593008355 <br /> Insured's Identification No. <br /> Ao Other workplaces not shown above: <br /> 37912 7TH AVENUE ZEPHYRHILLS FL <br /> 2. Policy Period: The policy period is from 01/15(2009 to 01/15/2010 12:01 A.M. Standard Time, <br /> at the insured's mailing address. <br /> 3. Coverage: <br /> A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states <br /> listed here: <br /> FL <br /> B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of <br /> our liability under Part Two are: <br /> Bodily Injury by Accident $ 100,000 each accident <br /> Bodily Injury by Disease $ 500,000 policy limit <br /> Bodily Injury by Disease $ 100,000 each employee <br /> C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: <br /> D. This policy includes these endorsements and schedules: <br /> SEE ATTACHED ENDORSEMENT WC 99 00 06 A 05 05 <br /> 4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating <br /> Plans. All information required below is subject to verification and change by audit. <br /> Classifications Code Premium Basis Rate Per Estimated Annual <br /> No. Total Estimated $100 of Premium <br /> Annual Remuneration Remuneration <br /> ` SEE ATTACHED ENDORSEMENT WC 99 00 06 A 05 05 <br /> Experience Rating Premium Expense <br /> Modification Discount Constant <br /> Factor <br /> 1.000 0.00000 % $ 200.00 Total Estimated <br /> Annual Premium $ 2,586.00 <br /> Deposit Premium $ <br /> ❑ This is a Three Year Fixed Rate Policy Minimum Premiui'n $ 237.00 <br /> Premium Adjustment Period: ® Annual; ❑ Semiannual; ❑ Quarterly; ❑ Monthly <br /> AGENT: CENNAIRUS, LLC <br /> i { ' <br /> 'f / <br /> SARASOTA, FL 34277 - Countersigned By — % P.O. BOX 25897 <br /> / / ` <br /> /Authorized Repree <br /> THIS INFORMATION PAGE WITH THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br /> t <br /> .:,. , :� " 4 "�" 1 ENDORSEMENTS IF ANY ISSUED TO FORM A PART THEREOF CO MPLETES THE ABOVE NUMBERED POLICY. • , a 7 <br /> _ t <br /> W C DD 00 01A ' r - s ' w . s .... :: .r- 4,. '�# se • v r'---- . '1 f t a * �. <a.o z .�. .", r 4 - c ` ' i <br /> ' '. JDL 6300 01 E d 5- 881 , " ' - ;5„ . .- ra'r ., ,-" ,.� , m0 n • r ;xw n ;, a .i� a3 «. ... x -� <br /> � Coopnght 1987 ational Counal an Comoensahon Insurance '' S 4 p e . ' <br /> r --�+ S ". ' v * ... , ."$' ` '` ,, t 4 . +'h kl la 'X?.10 `r�As�4, 8,2,, . 2 .t , ' t;`• , , 'Page of 1 '"� s._ <br /> ' . * i - iAt '•. .* , ei l= w . f. f T1'ri w -e- 1 _ 1-F 4 , w ' 1 . ,.. <br /> *, :. xG.,a s *-- - � ,. 4. .- � ,# 'w ... •�S fS ? " - <br /> y [ <br /> 1 _ vcB" g ' A °" may... . .� � �' �'�.� ".+.- <br />