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11 ,' 03 , 12004 16 : 17 FAX 772 4651013 EXCHANGE CLIfB CASTLE zoo , <br /> r <br /> INFORMATION PAGE (Continued) Policy Number: 21 WB DU9567 <br /> a. A, Workara Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the <br /> states listed here: FL ( SPO ) . <br /> E. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. <br /> The lirnits of our Iiablli: under Part Two are: <br /> Bodily injury by Accident $ 500 , 000 each accident <br /> Bodily Injury by Disease $ 500F000 policy limit <br /> Bod fly Injury by Disease $ 500 , 000 each employee <br /> C, Other States Insurnrlce: Part Three of the policy applies to the states, if any , listed hare: <br /> CA <br /> ALL STATES M: EPT ND , OH , WA , WV, WY , AND <br /> STATES DESIGNATED IN ITEM 3 . A . OF THE INFORMATION PAGE . <br /> �+ <br /> 0 <br /> -+ D. This policy Includes these endorsements and schedule: <br /> WC 99 00 05 WC 00 04 06 WC 00 04 20 2G2240 21) WC 00 04 14 <br /> Ln WC 00 04 19 WC 09 06 06 WC 99 02 78 <br /> R4. The premilum for this policy will be determined by our Manuals of Ames, Clasalfi anions, Rats$ and Rating <br /> Pkm. All lirlormation required below is vubject to verification and clue b audit. -- -- _- <br /> Premium I3esla <br /> Classifications Total Estimated Elates Per Estimated <br /> Code Number and Annual $1d0 of Annual <br /> log (Description _ _ Remuneration Remuneration Premium - - <br /> ( SEE ATTACHED SCHEDU.JAES ) <br /> INCREASED LIMITS PAR': TWO ( 9 8 0 7 ) 080 PERCENT 79 <br /> TOTAL PREMIUM StTB EC". TO EXPERXENCE MODIFICATION 100001 <br /> —=®- FL -- INTRA FiPERIENCF:: MODIFICATION 091190907 1 , t' 10 <br /> PREMIUM ADJUSTED BY A.E"PLT_CATTON OF EXPERIENCE MODIFICATXON 10 , 111 <br /> ,r TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 10 , 1Lt1 <br /> PREMIUM DISCOUNT 1 . 8 PERCENT -- 19 <br /> ENSE CONSTANT ( 0900 ) 20G, <br /> TERRORISM RISK INS AC"" OF 2002 ( 9740 ) 861 , 251 . 030 258 <br /> TOTAL ESTIMATED ANNUAL PREMIUM . 10 , 377 <br /> t� <br /> Total Estimated Annual Premium : $ 10j377 <br /> Deposit Premlum ; <br /> Policy) Minimum Premium : $ 334 FL ( INCLUDES INCREASED LIICT MIN . PREM . ) <br /> IrttsrstaWntrastate Identificsdlon Number: / 091190907 <br /> Labor Contractors Policy Number: Sic: <br /> (Form WC 00 00 01 A (t ) Printed in U.S.A . Page 2 <br /> ProoessDate; 09 / 10 / 03 Policy EVIratlonDate : ". 2 / 01 ; 4 <br />