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INFORMATION PAGE {Continued) Poliry Number fi3 ���� Rx��os <br /> 3. A. Workers Compensation Insurance: Part one of the palicy applies to the Workers Campensation Law of the <br /> states listed here AL, AZ, AR, CA, CO, DE, FL, GA, IL, IN, �CY, LP., MD, :�] �, h9N, <br /> MS, '•10, bt_ SEE EIQD: <br /> B. Employers Liability Insurance: Part Twa of the policy appiies to work in each state listed in Item 3.A. <br /> The limits of our liabiliry under Part Two are� <br /> Bodlly injury byAccident 5� , 000, o0o each accident <br /> Bodily lnJury by Dlsease S� , 000, o0o policy limit <br /> Bodlly inJury by Disease S� , 000, o0o each employee <br /> � C. Other States Insurance: Part Three af the policy applies ta the states, if any , listed here. <br /> 0 <br /> M <br /> � <br /> -� P.LL S1:1TES EXCEPT ND, GH, r±A, :�iD <br /> oTA13S DEj=GNATED I_V IiE_+1 3.A. QF TH� =?�FOP,h?1iT10:d ?AG�. <br /> � <br /> � D. This policy includes these endorsements and schedule: <br /> :-1 <br /> � {r]C 99 00 05 WC 00 04 05 :�IC OG 04 05A 41C GO 04 G6 �rIC 00 03 =1� <br /> ° j"� ���'= <br /> �� <br /> � <br /> � 4. The premium for this policy will be determined by our F�anuals of Rules, Classifications, Rates and Rating <br /> � Plans. Ali lnformation required below is subject to verification and change by audit. <br /> c <br /> � Premium Basis <br /> ° Classifications Total Estimated Rates Per Estimated <br /> � Code Number and Annual $100 of Annual <br /> _ Description Remuneration Remuneration Premium <br /> � (SE� A.^.^.^�.^HED S�.FiEDUL?Sj <br /> _ =�CREri�=D L=!�II^S P�.RT ^L'd��� ( 3312 i 2, 648 <br /> � C� ^_ER&.ITORI�.L DIFFER3��1=� PRELIIU 9694 (0.950) -?Og <br /> �- ^_G^_P.L PP.=41IJ`�l SLBJ3�_^ ^O ?X?�RIE��CE bIOD=F-CA_^IQ�1 _p� , ;6? <br /> � - <br /> _ PREMIL761 ^�A7USTED bY A?_LICATIOTv OF ?X=?RI?ti�.: �IODIF_C�i2QPi 98, ,__ <br /> � S�"H����7L? _'11Q��=FI`A1 � ON 1z, 77g <br /> � ='Oi::L =Si=bt4^�D �iv�J�Z STn'�i�•�RL• PR�'�IIJi•] '_22, 8�0 <br /> � PR'?t'•tIUi•] D=SCOiJ�; = -� , S �� <br /> � EX2�?SS� CO?�S^P�d^_ (0300;� <br /> G�G <br /> � ^vTP.L = ST=Ni�^_ ED �! A^_ � SiTFcCHAR�?� _ , ? r i <br /> � '='ERRGR � S:�I ( 9 i'_ 0) 5, 83 3 <br /> � =�RRGR�S:�I ly?4p) ?3R C-�I^_:s � <br /> = CF.T�r`.STRC=H3 (a74_? <br /> _ " 2,i88 <br /> � CATASTRC�?H? {9741; ?cR C4?=T� � <br /> � iOT:.L -S'_'=hLyTED .'v?�Z�Jr.L PR3P•lIUi•1 _29, 564 <br /> � <br /> � . <br /> — Total Estimated Annual Premium: s� z�, Fb� <br /> — �eposit Premium: �!-_ <br /> � Palicy Minimum Premium: $1, i5o IL ,_VCLUDES I��cR�'� LIti[=T ��_v. _R��t. ) <br /> Interstatellntrastate Identification Number: 9 '="-9?a22 % <br /> li:.ICS: �53995 <br /> Labor Contractors Policy Number: SIC: s��9 <br /> Form WC 00 00 01 A (1) Printed in U S.A. Page 2 <br /> Process Date: �?/3o/1i Policy Expiration Date: '�?!3� /12 <br />