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,Aiaa4. ... . •.�. ..vaNvtauVtt •wwnnon, 4�u MFENSATION EMPLOYERS LIABILITY <br /> moiINSURANCE POLICY-INFORMATION PAGE <br /> 34 <br /> ,;'FL 232-0303 - <br /> Policy Number Fro <br /> molicy Period <br /> To <br /> WCX 0014034 10 / 03 / 2006 10 / 03 /2007 <br /> 12-01 A.M. Standard Time at the desa-be locebon <br /> RENEWAL DECLARATION TtanSaCtfOn RenewallRewrite Of Policy No .q.: <br /> DIRECT BILL WCX 0014034 <br /> .. . . . . . . .. . . .. . <br /> • " Named insured and Address <br /> KIDS CONNECTED BY DESIGN INC Agent <br /> 117 ATLANTIC AVENUE BRAISHFIELD FL <br /> FT PIERCE FL 34950 5955 T G LEE BLVD STE 200 <br /> ORLANDO FL 32822 - 4423 <br /> Telephone: 407 - 825 - 9911 <br /> Carrier p FEIN # 0002244 <br /> 13714Risk ID ! Entity of Insured <br /> 650948854 091423537 CORPORATION <br /> Additional Locations: See Site Location Schedule <br /> 2 . The Policy Period is from 10 / 03 / 2006 to 10 / 03 / 200712: 01 a . m . Standard Time at the Insured 's mailing address . <br /> 3 . A. Workers Compensation Insurance: Part ONE of the policy applies to the Workers Compensation Law of the states <br /> listed here: FL <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 $ <br /> 100 , ODO each accident <br /> Bodily Injury by Disease $ Soo , 000 <br /> Bodily Injury by Disease $ policy limit <br /> 100 , 000 each employee <br /> C . Other States Insurance: Part THREE of the policy applies to the states, if any, listed here: <br /> ALL STATES EXCEPT NORTH DAKOTA , OHIO , WASHINGTON , <br /> WEST VIRGINIA , WYOMING , STATES DESIGNATED IN ITEM 3 . A . <br /> D. This policy includes these endorsements and schedules: See attached schedule. <br /> 4• 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 EXTENSION OF INFORMATION PAGE <br /> Minimum Premium $ 275 <br /> Total Estimated Annual Premium $ 11 , 357 <br /> Expense Constant $ 200 <br /> Premium Discount $ - 696 <br /> Deposit Premium $ 11 , 357 <br /> ❑ This is a Three Year Fixed Rate Policy <br /> Premium Adjustment Period: ® Annual ; ❑ Semiannual ; ❑ Quarterly; ❑ Monthly <br />:ountersigned this Day of <br />: sued Date: 09 / 19 /2006 r <br />;suing Office Sarasota , FL Authorized ,_p're,46ntative( <br /> 4 <br />'0074071-1 Ed. (09-04) <br />:DDDODIA 405-881 <br /> INSURED COPY <br /> Page 1 of 4 <br />