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/18/2007 10 : 14 FAI r¢ u02 <br /> AmCOMP Preferred Insurance Co. c$iate tVumbor ;' ,, ' � <br /> P.O. 9088�08 <br /> Norlh Palm BaKh, FL 33408.8808 5000236 , 06/23/2007 06/ 23 /2008 <br /> (800)228.1898 slat ati� n. a�n.me.. xm. <br /> On= DECLARATION <br /> flNf�'hkRltYd;6a7F�1fTt(CAC!'. ,:::_:. . . . . . : . . ':. <br /> BIG BROTHERS BIG SISTERS OF ATLANTIC PACIFIC INS . (PBG) 0247010 <br /> ST LUCIE COUNTY INC 11382 PROSPERITY FARMS RD <br /> 4131 S . US RWY 1 SUITE 123 <br /> PORT PIERCE FL 34982- 0000 PALM BEACH GARDENS , FL 33410- <br /> Telephone: ( 561 ) 6241800 <br /> CLatomerY Cartier r FEIN A Risk w ■ EnBty at kr o <br /> 31283 592455513 091388294 ASSOCIATION <br /> Additional Location: <br /> 2. The Policy Period Is from 06/23 /2007 t0 06/23/2008 12:01 a.m. Standard Time at the Insrsed's mailing address. <br /> 3. A. Workers Compensation Insurance: Part ONE of the policy applied to the Workers Compensation Lew of the states <br /> listed here: Florida <br /> B. Employers Liability Insurance: Part TWO of the policy applies to work In each state listed in Item 3A. <br /> The Iimks of our liability under Pat TWO are: <br /> Bodily I*" by Accident $ lo0, 000 eachaccident <br /> Baily Injury by Disease $ 5o0, 000 policy limit <br /> Bodily Injury by Disease $ 200 , 000 each ampkyee <br /> C. 00wr States Insurance: Part THREE of the policy applies to the states, If arty, listed here: <br /> AIDC,FL,GA,IN,K%KY,MD,MN,SC,TN,TX,VA <br /> D. This policy includes these endorsements and schedules: See akadted schedule. <br /> 4. The premium for this policy will be determined by our Manuals of Rules, Classft2d ns, Rates, and Rating Plans. <br /> All Information required below is subject to verification and charge by audit. <br /> Premium Basis Rate Per Esthnated Policy <br /> St, Loc Code Classification Description Total Estimated $100 of Term Premium <br /> No. Annual Rerrarneratlon Remuneration <br /> SEE EXTENSION OF INFORMATION PAGE <br /> Mlnlmum Premium $ 317 Total Estimated AnnualPramlum $ 14 , 132 <br /> QnOIS Date: 06/ 19/07 - <br /> IsstingOffice AmCOt@ Preferred Insurance Co . <br /> QUOTE ONLY AGENT <br />