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11 / 28 / 2007 13 : 33 FAX 772 4656013 EXCHANGE CLUB CASTLE Z003 <br /> Workere Compensation and Employers Liability <br /> Insurance Fa4ey <br /> Arilox 88806 Preferred Insurance Co. :fi x::: :..: « ►.: <br /> :::::,:;:y::::, .`. ....:::::::::::::.-::::::::::::::>;::.�i=;rxirn. y; :ci#:: "is,:s:> . Or>sia : 'r;: <br /> PI- <br /> Porth PamBea WCV 7072216 07 / 01 / 2007 07 / 01 /2000 <br /> .North Palm Beach, F1 33408-8806 tam .vN. sma ime ai iha add mw of tho <br /> I `0)226-1898 Ina�ed w =wiian:in <br /> .; I.. <br /> .I . . n Yljstt <br /> POLICY DECLARATION Effective : 07 / 01 / 2007 <br /> Yreflatn •:f : ,.•. <br /> ed tis ar <br /> tH7ad.. .A. . ; ;;:;; < ;;<ck: : : : :+:.::::::::::::: : :.:::.:: +;;;;: :_;:::afiIs:;: :;a•;:.;:ss;: t; i : ;:;: <br /> _....._................................. ...I............;I:I:I -::::......-.. ..._: ::.. <br /> EXCHANGE CLUB CENTER FOR THE BROWNING CORPORA^_ ION 0769010 <br /> PREVENTION OF CHILD ABU9Z OF 100 AVENUE A SUITE 1F <br /> P O BOX 12908 FT - PIERCE , FL 3 .4950 <br /> FORT PIERCE FL 34979 <br /> Telephone: 772 -465 - 8425 <br /> Customer # Carrier # FEIN # Risk ID # Entity of Inaured <br /> 31283 592094472 091190907 1 CORPORATION <br /> Additional Locations: <br /> 2- The Policy Period is from 07 / 01 / 2007 to 07 / 01 / 2008 12:01 a.m. Standard Time at the Insuredrs mailing address. <br /> 3. A. Workers Compensation Insurance: : Part Pr ONE of the policy applies to the Workers Compensation Law of the states <br /> fisted here: Florida <br /> B. Employers Liability Insurance: Part TWO of the policy applies to work in each state listed in Item 3A. <br /> The limits of our liability under Part TWO are: <br /> Bodily Injury by Accident $ 1 , 000 , 000 each accident <br /> Bodily Injury by Disease $ 1 , 000 , 000 policy limit <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 /> AL,DC, PL,GA, IN ,KS,KY, MD, MN, SC,TN,TX,VA <br /> 4 D. This policy includes these endorsements and schedules: See attached schedule. <br /> The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans. <br /> All information required below is subject to verification and change by audit. <br /> SEE EXTSNISIOfd MJF INFORKPATION P.AGE <br /> Minimum Premium $ 695 Expense Constant $ 200 <br /> Premium Discount $ - 1 , 753 <br /> Assessments and Taxes $ Total Estimated AnnualPromium $ 28 , 075 <br /> ❑ This is a Three Year Fixed Rate Policy <br /> l Premium Adjustment Period: 0 Annual; ❑ Semiannual; 0 Quarterly; ❑ Monthly <br /> Countersigned this Day of PIP <br /> Issued Date: 08 / :LG / 07 Authorized Representative <br /> Issuing Office Am=W Preferred Insurance Co . <br /> INSURED <br />