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Additional Looilldons: <br />2. The Policy Period is fromOMSAM lb 07116!2023 12:01 a.m. StoWard Time at the IrgtAlttrnalling address. <br />3. A. Workers Compensa*01lAMlllgn part ONE of the policy applies to the Workers C Mpool n law of the states <br />listed here: FL <br />A Suip1loWs Liabft tnsuhnm Part TWO of the policy appbs to work in each state wed in Nift. <br />111p ftft of our liability tinder Part TWO are: <br />Bodily Injury by Accident $ 1,000,000 each accident <br />Bodily Injury by Disease $ 1,tiDD;t policy limit <br />Bodily Injury by Disease $ 1,tXf0,t each employee <br />G Dow fillo a Insurance: Part THREE of the policy applies I* #* states, if any, listed here: <br />Ap stetds except ND. OH, WA, WY and states listed in item 3A. <br />M Tiff poleytrtdudes theseelmlimsements and schedules: See attached schedule. <br />+4. Thep unium fore poft will bedeiermined by our Manuals of Rules, Classifications, Rates, and Rating Plans. <br />AN k*ffmtion, requk+lMd beim is sttljsct to verification and by audita <br />SIE EMIUM OF INFORMATION PAGE <br />Minhimm Pt It ; <br />406 <br />Expense Constant $ <br />160 <br />Premium Discount $ <br />-301 <br />aa111 Taxes $ <br />Total Estima lSd AnnualPremium j <br />13,484 <br />C);TW is a Three Year Fixed Rate Policy <br />O1tMllklm Adjustment Period: <br />Annual; <br />❑Semiannual, QGhowift Q Mogft <br />_,,�..—..••+ <br />fta-•,d Oft. OYnM= <br />Issuing Olike:DANCE <br />MOW.11111053 <br />CO. <br />9003 <br />INSURED:.'Y. <br />Page 1 of 4 <br />