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oa (Policy Pravisions: %`�� �o 00 0o A} <br /> 42 <br /> Rx INFORMATION PAGE <br /> `�`'=� 1NORKERS COMPE ATiON AND EMPLOYERS LI LITY POLICY <br /> INSURER SEE AITACHE ENDORSEPd�N^_ <br /> NCCI Company Number: 1497� �HE <br /> Company Code: 5 <br /> TWIN CZTY FIRE INSIIRANCE COMPANY IS R£QIIIR�D I�ARTFORD <br /> BY LAW TO PROVIDE ITS POLICYHOLDBRS WITH CERTAIN <br /> ACCIDE�PT PREVENTION SERVICES AT NO P_DDITIONAL COST AS REQiTIRED BY ARR. CODE <br /> ANN. ' 11-9-409 {D} p.ND RUI,E 32. IF YOII WOUI,D LIKB MORB INE'ORMI�TION, CALL <br /> � THE HAf2TFORD, LOSS CONTROL DEPARTMhiVT, HARTFORD PLAZA, CALD-2-45, E3ARTFORD, <br /> ° CT 06115, 1-860-547-7761. IF YOII BAVE ANY QIIBSTIONS ABOUT THIS REQUIRE- <br /> ..-�i MENT, CALL THE HEALTS P.ND S�FETY DIVISION, ARXANSAS WORKERS COMPENSATION <br /> CO_MMISSION AT 1-800-622-4472. Suffix <br /> � <br /> LARS RENEWAL <br /> � POLICY NllMBER: �3 �aF Rx�2oa o0 <br /> � Previous Policy Number: �;�tiv <br /> ° HC�Us21�;G CGDE : �•H <br /> �i <br /> � 1. Named Insured and Mailing Address THR � yssoc_r^ts CGRPOP�i:TI0�1 <br /> � (Na , Street, Tawn, State, Zip Code) <br /> m <br /> � <br /> c <br /> c s2G�J PL3:SAtiT RJV <br /> N FEIN Number: � '�'�� 22 s 95 S?RI�;GF2EL�•, =L 62 ; 11 <br /> � <br /> State ldentification Number(s): <br /> '= t•lI. R=�K =�• t�'O: 210000G00 <br /> The Named Insured is: S'��H-'D'=� �^�RP <br /> = Business of Named Insured: s^oRES - v o c- tio Foc�n o� DR <br /> .. � <br /> Otherworkplaces not shown above: �Er, ='i°I' ='�x��• s�x��•JLEs <br /> 2. PolicyPeriod: From �''i-�'=/ To �';=s <br /> = 12 01 a.m,, Standard time at the insured's mailing address. <br /> = Producer's Name: "J '-`i � ��h[��;�� <br /> � <br /> � FO B��X 130?3 <br /> S?RI�GFI�LD, =L 52?9= <br /> — Producer's Code: �5a591 <br /> "' Issuing Qffice: ='x� H-�z='FC�r�� <br /> 8711 Lr1=tiERS=TY E:.ST DRIVE <br /> - CHr.RLOT^� VC G�L1� <br /> � <br /> �+. ��s77j 853-2582 <br /> Total Estimated Annual Premium: `? 2 Q, 5�� <br /> — Deposit Premium: `�'� <br /> — Policy Minimum Premlum: S1 , =50 IL ( I�;CL�.JI'iES =PvCR�-:S�D L=PdIT `�t_T�i . PRENI .; <br /> - Audit Period: ���J� Instaliment Term: <br /> — The policy is nat binding unless countersigned by aur autharized representative. <br /> -' Countersigned by <br /> Authorized Representative Date <br /> Form WC 00 40 01 A {1} Printed in U S A. Page 1(Continued an next page) <br /> Process Date: �'s % 3 0 �? „ � , -. <br /> Policy Expiration Date: i � - � - <br /> �.r�r �oDY <br />