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f <br /> R50 OMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br /> WC 99 06 01 A <br /> INFORMATION PAGE <br /> Insurer : <br /> Harbor Specialty Insurance Company Producer : Agent # 722 <br /> C/O AmeriComp Administrators , Inc . Sid Banack Insurance <br /> 5951 Cattleridge Blvd . , Suite 200 P . O . Box 130 <br /> Sarasota , FL 34232 Vero Beach , FL 32961 <br /> ( Carrier Code : 35270 ) 024 <br /> Carrier Policy # :Carri099000004981202 <br /> 1 . The Insured : Cultural Council of Indian RivereCounty ,PriorPolicy ; NEW <br /> Mailing Address : 2145 14 Ave I11 Type of Business : Corporation <br /> Vero Beach , FL 32960 <br /> Other workplaces not shown above : <br /> Fein : 593299133 <br /> NO OTHER WORKPLACES FOR THIS POLICY <br /> Risk ID : <br /> 2 . The policy period is from 12 : 01 a . m . on 12 / 20 /2002 to 12 : 01 a . m . on 12 /20 / 2003 <br /> at the insured ' s mailing address . <br /> 3 . A . Workers Compensation Insurance : Part One of the policy applies to the Workers <br /> Compensation Law of the states listed here : <br /> FL <br /> B . Employers Liability Insurance : Part Two of the policy applies to work in each <br /> state listed in Item 3 . A . The limits of our liability under Part Two are : <br /> Bodily Injury by Accident <br /> $ 100 , 000 each accident <br /> Bodily Injury by Disease <br /> $ <br /> Bodily Injury by Disease 500 , 000 policy limit <br /> $ 100 , 000 each employee <br /> C . Other States Insurance : All states except Nevada , North Dakota , Ohio , Washington , <br /> West Virginia , Wyoming and states designated in item 3A <br /> D . This policy includes these endorsements and schedules : <br /> WCOOOOOOA ( 04 / 92 ) WC000308 ( 04 / 84 ) WC000414 ( 07 / 90 ) WC090606 ( 10 / 98 ) <br /> 4 . The premium for this policy will be determined by our Manuals of Rules , <br /> Classifications , Rates and Rating Plans . All information required below is subject <br /> to verification and change by audit . <br /> Classifications Code <br /> Premium Basis Rate Per <br /> No . Total Estimated Estimated <br /> Annual Remuneration $ 100 of Annual <br /> Remuneration Premium <br /> SEE SCHEDULE OF OPERATIONS <br /> Total Estimated Annual Premium $ 2 , 180 . 00 <br /> Minimum Premium $ 730 . 00 <br /> WC 9 Ex a,- -onstt��°�----X90 . 00 <br /> 9 06 O1 A Countersigned by �= * <br />