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*3500121GD77000101 <br />.00 <br />77 <br />GD <br />WEC <br />(Policy Provisions WC 00 00 00 B) <br />INFORMATION PAGE <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY <br />INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY <br />ONE HARTFORD PLAZA, HARTFORD, CONNECTICUT 06155 <br />1. <br />NCCI Company Number: <br />Company Code: 6 <br />10456 <br />POLICY NUMBER: <br />Previous Policy Number: <br />HOUSING CODE: DV <br />Named Insured and Mailing Address: INDIAN RIVER COUNTY HEALTHY <br />(No., Street, Town, State, Zip Code) <br />21 WEC GD7700 <br />21 WEC GD7700 <br />FEIN Number: 650363222 <br />State Identification Number(s): <br />UIN: <br />333 17TH ST STE 2R <br />VERO BEACH, FL 32960 <br />The Named Insured is: CORPORATION <br />Business of Named Insured: CIVIC ORGANIZATION <br />Other workplaces not shown above: 333 17TH ST STE 2R <br />VERO BEACH <br />2. Policy Period: <br />Producer's Name: <br />Producer's Code: <br />Issuing Office: <br />FL 32960 <br />From 05/03/15 To 05/03/16 <br />12:01 a.m , Standard time at the insured's mailing address. <br />WILLIS OF FL INC/PHS/VERO BEACH <br />PO BOX 29611 <br />CHARLOTTE, NC 28229 <br />227667 <br />THE HARTFORD <br />8711 UNIVERSITY EAST <br />CHARLOTTE <br />(866) 467-8730 <br />DRIVE <br />NC 28213 <br />THE <br />HARTFORD <br />Suffix <br />LARS RENEWAL <br />13 <br />(SEE ENDT) <br />Total Estimated Annual Premium: <br />Deposit Premium: N/A <br />Policy Minimum Premium: $221 <br />FL <br />$607 <br />Audit Period: ANNUAL <br />The policy is not binding unless countersigned <br />Installment Term: <br />by our authorized representative. <br />Countersigned by d`eeya" <br />Authorized Representative <br />02/28/15 <br />Date <br />Form WC 00 00 01 A (1) Printed in U S.A Page 1 (Continued on next page) <br />Policy Expiration Date: 05/03 /16 <br />Process Date: 02/28/15 <br />ORIGINAL <br />