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FW A FLORIDA WORKERS' COMFENSATION <br /> JOINT NNDERWRNING ASSOCIATION, INC. <br /> WORKERS COMPENSATION <br /> I AND <br /> EMPLOYERS LIABILITY POLICY <br /> TYPE AR INFORMATION PAGE WC 00 00 01 ( A) <br /> POLICY NUMBER : ( GFR1 3UB - 281 7CG1 - 8 - 05 ) <br /> NEW- O5 <br /> INSURER : FLORIDA W . C . JUA <br /> 1 . NCCI CO CODE: 80179 <br /> INSURED: <br /> EXCHANGE CLUB CENTER FOR THE HARBOR INSURANCE AGENCY <br /> PREVENTION OF CHILD ABUSE OF AN AFFILATE or HA"OR rEOEx Ls VrNr BAN[ <br /> PO BOX 12908 2222 Colonial Road • Suite 100 <br /> FT PIERCE FL 34979 _ Fort Pierce, FL 34950-5309 <br /> 772-461 -6040 FAX 772-460-2315 <br /> harboria- com <br /> Insured Is A CORPORATION <br /> Other work places and identification numbers are shown in the schedule(s) attached. <br /> 2. The policy period is from 12 - 06- 05 to 12 -06 - 06 12:01 A. M . 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 state(s) listed here: <br /> FL <br /> B . EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in <br /> item 3.A. The limits of our liability under Part Two are: <br /> Bodily Injury by Accident: $ 500000 Each Accident <br /> Bodily Injury by Disease: $ 500000 policy Limit <br /> Bodily Injury by Disease: $ 500000 Each Employee <br /> C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: <br /> SEE ENDORSEMENT FWCJUA 03 01 <br /> D . This policy includes these endorsements and schedules: <br /> r� SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE <br /> 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating <br /> Plans. All required information is subject to verification and change by audit to be made ANNUALLY . <br /> DATE OF ISSUE: 01 - 06 - 06 HS ST ASSIGN : FL <br /> OFFICE: FLORIDA WC JUA 821 <br /> PRODUCER: HARBOR INSURANCE AGCY 2369) <br /> 016133 <br />