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'I <br /> ; INFORIU�ATION PAGE �Gontinued) Policy Numher: a3 wE Rx42oa <br /> � 3.A, Workers Compensation Insurance: Part ane af the pallcy applfes to the WorEcers Compensatian Law of the ; <br /> , states Ilsted here:AL, AZ, �1R, CA, CO, DE, FL, GA, IT., 2N, IA, KS, IfY, LA, ME, <br /> MD, MA, MZ SEE END'I' <br /> B. Employ�rs Llability Insurance: Part Two af the policy applies to wark in each state listed in Item 3,A, <br /> 7he limits �f aur I(ability tander Part Two are; <br /> Bodlly InJury hyAccldent S1, 000, o0o each accldent <br /> Bodlly Injury by Dlsease $�, oao,o0o po���y ��mp� <br /> Bodily Injury by Dlseas� $1, 000,o0o each employee <br /> � C. Other States Insurance: Part T�ree of the policy applies ta the states, if any, Iisted here; <br /> � <br /> � <br /> �i AI.L S'E'ATES EXCEPT ND, OH, WA, AND <br /> STATES DESIGIVA'I`ED IN IT�M 3.A. OF THE TNF�ORMATION PAGE. <br /> o D. This policy Includes these endarsements and schedule: <br /> � <br /> � WC 99 00 05 WC 00 04 06 WC 00 04 06A WC 00 04 06 F1C 18 06 07A <br /> iJL` 'L` J".aJ.VL1 <br /> nl . <br /> � <br /> � 4. 7he premium for thls policy wlll be determined by qur Manuals of Rules, Classlficatlons, Rates and Ra#ing <br /> � Plans. All lnformation requlred below Is subjeet to verification and change by audit. <br /> 0 <br /> � Premium Bas1s <br /> ° Classlflcatlons Total Estimated Rates Per Estimated <br /> * Code Number and Annual $1fl0 of Annual <br /> � Descrip#ion Remuneration Remuneration Premium ' <br /> � (��EE A'I'I'ACHEI} SCHELIULES) <br /> � INCREASED LIMTT'S PART TWO (9812} 3,606 <br /> = CA TERRI�'QRIAL DIFFERENTIAL PREMTUM 9694 (0.950) -26� <br /> � TOTAL PREMIUM SUBJECT TO EXPER2ENCE MODIFICATTQN 141,257 <br /> � PREMIUM ADJUSTED BY APPLICATION OF EXPER2ENCE MODIFTCATIbN 219,295 <br /> � SCHEDULE MOD2FICATIdN 35,254 <br />