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10/ 20- / 20OG 15 : 18 1772557113E 12HILL " ARE ?E3r7i_IPo^ES PAGE 62 <br /> INFORMATION PAGE (Continued) P <br /> ol 'cy Murtrber: 21 WEC LQ8 it 2 <br /> 3. A. Workers Compen8ation Insurance : Pan one of the policy applies t0 the Workers Comi ens:Q , on Lew of the <br /> states listed here' FL <br /> B. Employers Liability insurance : Fan wo of the f'at'ty applies to work In earl sts, :e listen M !tem 3 .A <br /> The limits of our liability under Part Two are <br /> Bodily injury by Accident $ 500 , 000 <br /> Bodilyeach dccident <br /> injury by Disease $ 500 , 000 policy limit <br /> Bodily injury by Disease $ 500 , D00 <br /> each employee <br /> C. Other States Insurance : Par. Three of the p0ficy applies to the states. if any , listed dere <br /> m <br /> ALL STATES EXCEPT ND , OH , WA , WG , WY , AND <br /> STATES DESIGNATED IN ITEM 3 . A DF THE INFORMATION PAGE . <br /> D This policy include$ these endursements aria schedule: <br /> 0 <br /> ro WC 09 04 03 WC 00 04 14 WC 00 04 19 WC 09 06 06 <br /> a <br /> m <br /> cr 4. The premium for this policy will be determined by our Manuals of Rules, Classifications , Rates ar :d Rat rig <br /> ra Plans. All information required below is subject to verification and change by audit. <br /> Premium Basis <br /> LP Classifications Total Estimated Rates Per Estimated 4 <br /> Code Number and Annual $ 100 of Annual <br /> Description Remuneration Remuneration Premiun _ <br /> 3111111111! 13 . 58 7a ' <br /> MillerCLERICAL OFFICE EMPLGYEES NO'=' <br /> ease <br /> INCREASED LIMITS PART TWC ( 9807 ; 130 PERCENT b <br /> q TO EQUAL INCREASED LIMITS MINIMUM PREW:IUM ( 9848 ) 94 <br /> TOTAL ESTIMATED ANN^JAL STANDARD PREMIUM 639 <br /> 1� EXPENSE CONSTANT ( 0900 ) 200 <br /> r� FOREIGN TERRORISM ( 9740 ) 136 , C00 . 030 41 <br /> Ifs TOTAL ESTIMATED AN-WAL PREMIUM 1 : 08C <br /> soft <br /> sum <br /> s <br /> Total Estimated Annual Premium ; $ 1 ( 080 <br /> > Deposit Premium : <br /> as <br /> = Policy Minimum Premium : $ 294 FL ( INCLUDES IN"'REASED LIMIT MIN . PREY - ) <br /> ae <br /> Interstate/Intrastate Identification Number: <br /> NAlCS : 511659 <br /> Labor Contractors Policy Number: SIC: 8299 <br /> Form WC 00 00 01 A 0 ) Printed in U- S .A . Page 2 <br /> Process Date : 06 1Yi 6 Policy Expiration Date: 10 / 14 / C7 <br />