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ISSUING COMPANY <br /> ACE PROPERTY & CASUALTY INSURANCE Workers' Compensation <br /> - woo/c^Rn�RCODE | <br /> and Employers Liability <br /> 122S4 ~° ~~ �"-� <br /> Insurance PoK^c� <br /> l ��m, NUMBER <br /> ~ <br /> L8 New <br /> � �m�� N�� Number. C4 G281 83g Renewal [] R�h� Information Page <br /> pnsxmuspoL�vwo <br /> ! ey�»u/ �un�ec LJ Individual [] Partnership <br /> | i g Corporation LIT <br /> Item1�_ <br /> Named � &ASS]CIATES CORPORATION |n»enlntrastatNo.: e ID No.: 913193822 <br /> Insured 3200 PLEASANT RUN <br /> SPRINGFIELD IL 62711 Federal EmployerlD No.: 800222606 <br /> mamn� <br /> Address <br /> L Employer's ID No.: <br /> PIIC CODE: 5399 <br /> For other named insured see Extens of Intormatiori Page-Scnedule of Named Insured, WC 99 99 99 A <br /> For other wor plmmeeeeE*onaionof|nfonnadonPaga-SokedulecdOtherVYorkplacea YYC90g9AQ <br /> Item 2. Policy period: From 03-31-2010 To 03-31-2011 12:01 A.M. standard time ar the named inoured's mailing address. <br /> Item 3A. Workers' Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the states listed here: <br /> AL.AZ.DE.FL.GA.|L.|N.KY.KN.K8N.KJ0.MS.N[WlNY.PA.TN.TX <br /> Item 3B. Employers Liabiiity Insurance: Part Two of the policy applies to work in each state hsted in Item 3A. <br /> Tne Hmits of our Iiabihty under Pal Two are: BodHy Injury by Accident $ 1,000 000 each accident <br /> Bodily Injury UyDisease $ 1 000.000 policy limit <br /> Bodily Injury byDisease $ 1 each employee <br /> item 3C. Other states Insurance: Part Three of the polcy applies to the states, 1 any. isted riere: <br /> -L STATES EXCEPT <br /> NO.OH.YV&VYY. <br /> AND STATES DESIGNATED IN ITEM 3.A <br /> Item 4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. Ail information <br /> required below io subject tuvahfioetiun and change byaudit. <br /> SEE EXTENS)ON OF INFORMATION PAGE -CLASSIFICATIONS <br /> If indicated here, interim adjustments of premium will be made: Minimum premium collected in IL $ 1000. <br /> Sern|'Annua|ly ___:Ouartor|y _]Monthly Total Estimated Premiurn $ 86097. <br /> Deposit Premium � <br /> This poUcy ncludes these endorsements and schedu!es: <br /> SEE SCHEDULE OF FORMS AND ENDORSEMENTS WC999999D <br /> PRODUCER NAME AND MAftING ADDRESS <br /> ARLINGTON/ROE & CO INC <br /> PO BOX 8O8O3 <br /> INDIANAPOLIS IN 46280 <br /> PRODUCER CODE: 228532 351150545 SML <br /> wxRxEnwso=p/cs: ACE COMPLETE <br /> ISSUE DATE: 03/31/2010 <br /> ^ 2z - <br /> ° <br /> <A il^rize« Schramm <br /> mKCOUUOO1A (06/03) Copyright 1eur National Council o" Compensation insurance <br /> 1 <br /> INSURED <br />