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F A FLORIDA WORKERS COMPENSATION <br /> JOINT UNDERWW14G ASSOCIATION, INC. <br /> WORKERS COMPENSATION <br /> AND <br /> EMPLOYERS LIABILITY POLICY <br /> TYPE AR INFORMATION PAGE WC 00 00 01 ( A) <br /> POLICY NUMBER : ( 6FR13UB - 2817C61 -8 - 05 ) <br /> NEW- 05 <br /> INSURER: FLORIDA W . C . JUA <br /> t NCCI CO CODE: 80179 <br /> INSURED : <br /> EXCHANGE CLUB CENTER FOR THE HARBOR INSURANCE AGENCY <br /> PREVENTION OF CHILD ABUSE OF "N�F1L1ATEO HARBOR FEOFRAC SWNL MNK <br /> PO BOX 112908 2222 Colonial Pocd • Suite 100 <br /> Fort Pierce, FL 34950-5309 <br /> FT PIERCE FL 34979 772-461 -6040 FAX 772-460-2315 <br /> harborio . com <br /> Insured is A CORPORATION Elm I <br /> Other workplaces 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 /> 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 /> Pians. 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 23B9J <br /> x161 as <br />