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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br /> INFORMATION PAGE <br /> NCCI Co.No. Policy No. <br /> 20850 Guarantee Insurance Company WCP100736404GIC <br /> A Stock Company Renewal of Policy No, <br /> Fort Lauderdale, FIL <br /> 401 E.Las Olas Boulevard,Suite 1540 WCP100736403GIC <br /> Fort Lauderdale,FL 33301 <br /> For questions,issues call 866-827-4669 <br /> ❑ Individual p Partnership <br /> ® Corporation or <br /> 1. The Insured/Wilingaddress; <br /> Ins ured's I.D.No{s}.,it applicable <br /> Big Brothers Big Sisters of St. Lucie,Indian 091388294 <br /> 403 N.US Hwy 1 FEIN 59 2455513 <br /> Fort Pierce,FL, 34950 <br /> Other workplaces nolshown above:NONE <br /> 2.The policy period is from 06/23/2016 to 06t23/2017 12:01 AM. Standard Time,at the ins,ued's mailing address. <br /> 3.A Workers Compensation Insurance: Part One of the policy applies to the Workers Cam pensationLawofthe states lis ted here: <br /> FL <br /> B.Employers Liability Insurance: Part Two of the policy applies to work in each state listed in ilem 3.A The limits of our <br /> liabilityunder Part Two are: Bodily Injury by Accident$ 1.000,000 each accident <br /> Bodily Injury by Disease$1,000.000 policylimit <br /> Bodily injury by Disease$1.000,000 each employee <br /> C.Other States Insurance: Part Three of the policy applies to the states,if any, listed here: <br /> ALL STATES EXCEPT: AK AZ CA CT HI IA IL KS MA MN ND NH OH PR RI UT Vr V1'.A WY <br /> D.This policy includes these endorsements and schedules:SEE SCHEDULEOF ENDORSEtvrNTS <br /> 4.The premium for this policywill be determined by our Manuals of Rules,Classifications,Rates and Rating Plans.All information required <br /> below is s ubjectto verification and change by audit. <br /> Code Premium Basis Rate Per 100 of Estimated Annual <br /> Classifications No. Total Estimated Annual Remuneration Remuneration Premium <br /> See Item 4.Schedule of Operations <br /> If indicated below,interim adjustments of premium MANUAL PREMIUM $15,306.00 <br /> shallbemade TOTAL MANUAL PREMIUM $15,306.00 <br /> Employers Liability(E/L)increasediints factor $214.00 <br /> ❑Semiannually,❑ Quarterly, D Monthly SUBJECTPREMIUM $15,520.00 <br /> Safety Factor -$310.00 <br /> Drug-Free Workplace Premium CrecU factor -$760.00 <br /> TOTAL SUBJECT PREMIUM $14,450.00 <br /> E)perience Modification $15,751.00 <br /> TOTAL MODIFIED PREMIUM $15,751.00 <br /> TOTAL. STANDARD PREMIUM $15,751.00 <br /> Premium Discount -$523.00 <br /> E)pense Constant $200.00 <br /> Terrorism $188.00 <br /> TOTAL ESTIMATED ANNUAL PREMUM $15,616.00 <br /> Minimum Premium $347,00 <br /> ameo ro ucer: PUIInsuranceency <br /> Producer Address: 401 E las Olas Blvd.Suite 1650, <br /> Ft Iauderdale,FL,33301 <br /> Countersigned By <br /> t orize epresenta'4a Date <br /> WC 00 0001 A <br /> (Ed. 1-15) <br /> THIS INFORMATION PAGE WITH THE WORKERS COMPENSATION AND EMPLOYERS LABILITY INSURANCE POLICY <br /> AND ENDORSEMENTS,IF ANY,ISSUED TO FORMA PART THEREOF,COMPLETES THE ABOVE NUMBERED POLICY. <br />