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00 (Policy Provisions: WC 00 00 00 B) <br /> 77 <br /> GD INFORMATION PAGE <br /> WEC WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY <br /> INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY <br /> ONE HARTFORD PLAZA, HARTFORD, CONNECTICUT 06155 <br /> NCCI Company Number: 10456 THE it <br /> Company Code: 6 <br /> HARTFORD <br /> N <br /> lD <br /> Ol <br /> ko <br /> O <br /> Suffix <br /> LARS RENEWAL <br /> C) POLICY NUMBER: 21 WEC GD7700 14 <br /> o Previous Policy Number: 21 WEC GD7700 <br /> HOUSING CODE: DV <br /> Q 1. Named Insured and Mailing Address: INDIAN RIVER COUNTY HEALTHY <br /> (No., Street, Town, State, Zip Code) (SEE ENDT) <br /> N <br /> -1 <br /> 0 333 17TH ST STE 2R <br /> Ln FEIN Number: 650363222 VERO BEACH, FL 32960 <br /> State Identification Number(s): <br /> UIN: <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 FL 32960 <br /> 2. Policy Period: From 05/03/16 To 05/03/17 <br /> 12:01 a.m., Standard time at the insured's mailing address. <br /> Producer's Name: USI INSURANCE SERVICES LLC/PHS <br /> PO BOX 29611 <br /> CHARLOTTE, NC 28229 <br /> Producer's Code: 227667 <br /> Issuing Office: THE HARTFORD <br /> 8711 UNIVERSITY EAST DRIVE <br /> CHARLOTTE NC 28213 <br /> (866) 467-8730 <br /> Total Estimated Annual Premium: $593 <br /> Deposit Premium: N/A <br /> Policy Minimum Premium: $221 FL <br /> Audit Period: ANNUAL Installment Term: <br /> The policy is not binding unless countersigned by our authorized representative. <br /> Countersigned by 03/05/16 <br /> Authorized Representative Date <br /> Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) <br /> Process Date: 03/05/16 Policy Expiration Date: 05/03/17 <br /> ORIGINAL <br />