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11 :' 03 ' 2004 16 : 17 FAX 772 4656013 EXCHANGE CLUB CASTLE Z002 <br /> 67 (POIICy Provisions: WC 00 00 00 A ) <br /> 95 <br /> tea INFORMATION PAGE <br /> wB WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY <br /> INSURER * HARTFORD INSURANCE COMP&MY OF THE MIDWEST <br /> HARTFORD PLAZA , W& TFOR D , CONNECTICUT 05115 <br /> NCCI Company Number: SA= RTFt.I R <br /> Company Code : G <br /> N <br /> sr <br /> O+ <br /> O <br /> 6urflu <br /> LARS RENEWAL <br /> © Previous Policy Number: �y� rule � r.7 <br /> u'rDi HOUSING CODE: : DH <br /> 1 . Named insured and Mailing Address: EXCHANGE CLUB CENTER FOR THE <br /> (Na. , Street, Town , State, ZIP Code) PREVENTION OF CHILD ABUSE DBA ( SEE & TDT ) <br /> PO BOX 12908 <br /> r4 FEIN Number. 592094472 FORT PIERCE , FL 34979 <br /> State Identltication Number(s): <br /> r <br /> Nami <br /> .� 'Che Named Insured le: CORPORATION <br /> Business of Flamed Insured: COUNSEL TO PREV1. NT CHILD ABUSE <br /> 01her workplaces not shown above: S4E ATTACHED SCHEDUL..SS <br /> 29 ProlicyPerlod: From 12 / 0 .9. / 03 TO 121' 01 / 04 <br /> 12:01 a .m . , Standard time at the insureds mailing address. <br /> Producers Name: HARBOR INSURANCE AGENCY <br /> .w. <br /> 2222 COLONTAL ROAD , SUITE 100 <br /> FT PIERCE , FL 34950 <br /> Producer's Cade: 220020 <br /> SWENEW <br /> Issuing Office: TIDE HARTFORD <br /> 8711 UNIVERSITY EAST DRIVE <br /> mm CHARLOTTE NC 28213 <br /> Total Estimated Annual Premium : $ 10 , 377 - --- —� <br /> Deposit Premium : <br /> Policy Minimum Premium : $$ 334 FL ( INCLUDES INCREAS13D LIMIT MIN . PREM . ) <br /> Audit Period: ANNUAL Installment Tenn: <br /> The policy Is not binding unless countersigned by our authorized reprosentalive. <br /> Countersigned by � ,? , �. : `. • /, t , � // �C' /�' <br /> A.utharizeIre <br /> se alive Data <br /> l <br /> Form SWC 00 00 01 A (1 ) Printed in U .S.A. Page 1 (Continued on next page) <br /> Process Data: 09 / 1. 0 / 03 Policy 0Wirati*n Data: 12 / 01 / 04 <br /> ORIG2NAL <br />