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INFORMATION PAGE (Continued) Policy Number: 21 WEC GD7700 <br /> 3.A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the <br /> states listed here: FL <br /> B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. <br /> The limits of our liability under Part Two are: <br /> Bodily injury by Accident $100, 000 each accident <br /> Bodily injury by Disease $500, 000 policy limit <br /> Bodily injury by Disease $100, 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 ND, OH, WA, WY, US TERRITORIES, AND <br /> STATES DESIGNATED IN ITEM 3 .A. OF THE INFORMATION PAGE. <br /> D. This policy includes these endorsements and schedule: <br /> WC 00 04 04 WC 09 04 03B WC 09 04 07 WC 99 . 03 65 WC 00 04 14 <br /> WC 00 04 19 WC 09 03 03 WC 09 06 06 WC 09 06 07 <br /> 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating <br /> Plans. All information required below is subject to verification and change by audit. <br /> Premium Basis <br /> Classifications Total Estimated Rates Per Estimated <br /> Code Number and Annual $100 of Annual <br /> Description Remuneration Remuneration Premium <br /> 8810 164,100 .26 427 <br /> CLERICAL OFFICE EMPLOYEES NOC <br /> TOTAL ESTIMATED ANNUAL STANDARD PREMIUM . 427 <br /> EXPENSE CONSTANT (0900) 200 <br /> TERRORISM (9740) 164,100 .020 33 <br /> TOTAL ESTIMATED ANNUAL PREMIUM 660 <br /> Total Estimated Annual Premium: $660 <br /> Deposit Premium: N/A <br /> Policy Minimum Premium: $223 FL <br /> • <br /> Interstate/Intrastate Identification Number: <br /> NAICS: 813319 <br /> Labor Contractors Policy Number: SIC: 8641 <br /> UIN: <br /> NO. OF EMP: 2 <br /> Form WC 00 00 01 A (1) Printed in U.S.A. Page 2 <br /> Process Date: 03/04/17 Policy Expiration Date: 05/03/18 <br />