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10 ; G / 2006 15 : 16 1772567113E _HILL ARE ?L"dC_iRCES PriGE f� 2 <br /> INFORMATION PAGE (Continued) <br /> Po"cyNurr) ber: 21 WBC UQ6li2 <br /> 7 . A. Workers Compensation <br /> stales listed here' FL Insurance : Part one of the policy applies to the Iklorkers Corr:F nn Law of the <br /> B. Employers Liability Insurance : f-an wo of the policy applies 10 work .; ste in !tem 3 A <br /> The limits of our liability under Pan 7wc are III ea lister+ <br /> Bodily injury by accident $ 500 , 000 <br /> Bodily injury by Disease each decadent <br /> s 00 , OD0 Policylim � t <br /> Bodily injury by Disease s �lcU , 000 each employee <br /> P C . Other States Insurance: Pa+ ? Three rf the policy applies to the states , it any , listed hei n <br /> STATES EXCEPT ND , r <br /> JH , WA , W(i , WS , 14'VC <br /> STAPES DESIGNATED IN I^.'EM J . P. OF THE INFORMATION PAGE . <br /> n <br /> D This Policy includes these endorsernents and schedule: <br /> N WC 04 04 .03 <br /> WC 00 04 14 WC 00 04 19 WC 09 06 06 <br /> a <br /> m <br /> d. The premium for this policy will be determined by Our Manuals of Rules, Classifications. Rates and Rat rig <br /> Plans . Ali information required belowis subject to verification and change by autlit. <br /> Premium Basis ` — - - - -- - <br /> Classifications Total Estimated Rates Per <br /> Estimated <br /> Code Number and <br /> Annual $ 100 of Annual <br /> Description <br /> - -- Remuneration Remuneration Premiun <br /> 6810 —_'_-------- --- ------ 16 , 0 U 0 , � g -- �— - - — - <br /> nowCLP'RICAL OFFICE EMPLOYEE$ NO" I3 . <br /> INf.RF'ASED LIMITS PART, TWC ! ? B07 ` , 30 PERCENT b <br /> i TO :QUAL INCREASED LIMTTS MTNIWtt o YREbiI JM ( 9646r 4 <br /> TOTAL ESTIMATED ;L JAL STANDARD 9 <br /> FREMIUM 644 <br /> aI� EXPENSE CONSTANT ( 0900 ) 20C <br /> FOREIGN TERRORISM ( 47401 136 , 500 . 030 ql <br /> TOTAL ESTIMATED ANNUAL PRF,MIiJM 06C <br /> rc <br /> r� <br /> s <br /> Total Estimated Annual Premium: <br /> �—a Deposit Premium ! <br /> Policy Minimum Premium : — 6294 FL , IN!" LtJDES IN "cZEASE'D LIMIT MTN_PREM . ' <br /> Sale <br /> Interstate/Intrastate Identification Number: <br /> NAILS : 511649 <br /> Labor Contractors Policy Number: SIC: 3 .149 <br /> Form INC 00 00 01 A ( 1 ) Pirated in U S Page 2 <br /> Procass Dare ; 08 / 11 36 Policy Expiration Date : 10 / 19 / () 7 <br />