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x'19/ 2007 10 : 14 FAX 10ouz <br /> AmCOMP Preferred Insurance Co. t;ua[eNanthx, : . `"� ra <br /> P.O. Bm 88806 $000236 06/ 23�/20m07m�,y 06/23 /2008 <br /> Norlh Pd8808 m Beech. FL 33406- - 1 01 as w i am.maw. a" <br /> (800n28-1890 <br /> rtdbn <br /> Q= DECLARATION <br /> BIG BROTHERS BIG SISTERS OF ATLANTIC PACIFIC INS . (PBG) 024701D <br /> ST LDCIE COERM INC 11382 PROSPERITY FARKS RD <br /> 4131 S . US BWY 1 SUITE 123 <br /> FORT PIERCE FL 34982 - 0000 PALM BEACH GARDENS , FL 33410 - <br /> Telephone: ( 561 ) 6241800 <br /> Customers CefAeni FEINS ISek IDA Entity of hn"d <br /> 31283 592455513 691388294 ASSOCIATION <br /> Additional Locations: <br /> 2. The Policy Period is from 06/23 /200710 06/23/2Ooa 12:01 a.m. Standard Time at the insured's mailing address. <br /> 3. A. Workers Compensation Insurance: Part ONE of the policy apple9 to the Workers Compensation Law of ft stabs <br /> listed here: Florida <br /> 8. Employers Liability Insurance: Part TWO of the policy appiles to work in aach state elated in Item 3A. <br /> The limits d our liability undo Part TWO are: <br /> Bodily lnpgbyAcddmt $ 1o6, 000 eachaocklml: <br /> Bodily Injury by Dsease S 500, 000 policy limit <br /> Bodily Injury by Disease $ 100, 000 each empbyee <br /> C. other States Insurance: Pan THREE dthe policy applies to the states, V any, listed here: <br /> AL DC,FL,GA,IN,KS,KY,MD,MN,SC,TN,TX,VA <br /> D. This policy includes these endorsements and schedules: See attached sdnedula. <br /> 4. The premium for this policy will be detemNned by our Manuals of Rules, Classifications, Rates, and Rating Plans. <br /> Ali (mfOrtnal(on required below is subject to ver(ficailon and charge by audit. <br /> Premkm Bads Rate Per Estimated Policy <br /> St. Loo COde Classification DesQlplion Trial Estimwbd $100 of Term Premium <br /> No. Amaral Remuneration Remuneration <br /> SEE EXTENSION OF INFORMATION PAGE <br /> Minimum Prantum $ 317 Total Esdmeted AneualPr rnium y 14 , 132 <br /> Quote Date: 06/ 19/07 - <br /> issuing Office AmCOMP Preferred Insurance Co . <br /> QUOTE ONLY AGENT <br />