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10/ 26/ 20e16 15 : 16 1772567113E HILL7aRE PE CbiR ES PAGE 02 <br /> _ INFORMATION PAGE (Continued ) <br /> PollcyNunFber: 21 WBC DQe112 <br /> 7. A. Workers Compengahon Insurance: Pan one of the policy applies <br /> to the Workers Corrii +ensart; on Law of the <br /> states listed here: FL <br /> B. Employers Liability Insurance : Fan wo of the policy applies to work n ea , st ,, :e listen in ! tem 3 A <br /> The limits of our liability under Pan 7wc are <br /> Bodily injury by Accident $ 500 , 000 <br /> Bodily injury by Diseaseeach dccident <br /> $ 500 , 000 policy limit <br /> Bodily injury by Disease $ 500 , 000 <br /> each employee <br /> m <br /> C . Other States Insurance : Par. Three 0 the policy applies to the states, <br /> it any , listed her e <br /> a <br /> ALL STATES EXCEPT ND , r <br /> JH , WA , WV , FlY , AND <br /> STATES DESIGNATED IN ITEM 3 . A Cc THE INFORMATION PAGE . <br /> 0 <br /> D This policy includes these endursements and schedule: <br /> ayv WC 09 04 03 WC 00 04 14 WC 00 04 19 WC 09 06 06 <br /> a <br /> w <br /> c 4. The premium for this policy will be determined by our Manuals of Rules, <br /> Plans. All informmation required below is subject to verification and change b Classificattions. Rates and Rab ng <br /> audit. <br /> Classifications Premium Basis <br /> M Cade Number and Total Estimated Rates Per Estimated <br /> * Annual $ 100 of Annual <br /> Description <br /> Remuneration Remuneration Premiun <br /> Sim <br /> 1 6 , 000 - — - - <br /> MEMO CLERICAL OFFICE EMPLCYEES NO" . se , � <br /> 211111!e <br /> mom INCREASED LIMITS PART TWC ( 9807 ! . 30 PERCENT <br /> 2111111111 TO EQUAL INCREASED LIMITS MINIMUM PREMIUM ( 9848 ) 6 <br /> W TOTAL ESTIMATED AtQjAL STANDARD PREMIUM 44 <br /> 839 <br /> EXPENSE CONSTANT ( 0900 ) <br /> E 20C <br /> a� FOREIGN TERRORISM ( 9740 ) 136 , 000 . 030 <br /> an TOTAL ESTIMATED ANNUAL PREMIUM 41 <br /> 1 : 080 <br /> r: <br /> s <br /> nrr. <br /> oats <br /> Total Estimated Annual Premium : $ 1 , 080 <br /> ?iii Deposit Premium : <br /> Millis <br /> Policy Minimum Premium : $ 294 FL ( INCLUDES IN" REASED LIMIT MIN , PREM . <br /> Interstate/Intrastate Identification Number: <br /> NAIi; S : 511659 <br /> Labor Contractors Policy Number: SIC: 8299 <br /> Form WC 00 00 01 A (f ) Printed in U. S .A Page 2 <br /> Process Date : 08 / 19 / Z6 Policy Expiration Date : 10 / 14 / 07 <br />