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NOV - 11 - 2004 10 : 33 AM CULrURAL . COUNC ] L . IRC 77277OX403 P903 <br /> 7 <br /> WORMS COMPENSATION AND 3MPLGYERS _ IABILITY INSURANCE POLICY WC 99 05 01 A <br /> REISSUE INFORMATION PAGE RENEWAL AGREEMENT <br /> Insurer ; Producer : Agpntd 422 <br /> Harbor Specia _ ty Insurance Company Sid Barrack Insurance <br /> C / O Unisource Administrators , I . >?,0 , Box 130 <br /> 5951 Cattleridge Blvd . , Suite 2CO Vero Beach , FL 32961 <br /> Serasota , FL 34232 <br /> ( Carrier Code : 35270 ) 024 Ca :• _• '_ er Policy l : 0 ) 9000004981203 <br /> Cer ' ier Pr '_ ar Poli : y # : 099000004981. 202 <br /> 1 . The Insured : Cultural Co : r. cil of rndian River Co :; nty , <br /> Type of Business Corporation <br /> Mailing Address : 2145 14 Ave X11 <br /> Vero Beac :n , �zI. 32950 • <br /> Other vrkplaces not shown above : Fein : 593299 33 <br /> NO OTHER CORK ?LACE $ FOR ^. HIS PC- LICY Risk ID ; <br /> 2 . The nolicy period is from 12 : 01 t . m , on 12 / 20 / 2003 to 12 : 01 a . m . on 12420/ 2004 <br /> a - the ins •ared ' s mailing aedress . <br /> 3 . a . Workers Compensation Insurance Part One of the pClicy applies - n ; hs tvor. kers <br /> Compensation law of the states listed here : <br /> FL <br /> B . Tmployers Liability. Ir, Fur % ncCj : Pa _' t Two of _ }? e policy app _ ies to he rk <br />in each <br /> state listed in Item 3 . A . The lira of o =*- IA. abi, lity under Part Two are : <br /> Bcodily Injury by Accident $ 1 . 0 , 000 each accident <br /> Bodily Injury by Disease $ i 500 , 000 policy limi _ <br /> Bodily Injury by Disease $_ _ 100 . 000 each employc-e <br /> C . other States Insurance : <br /> D . This poli , y in.c _ udes these endorsemert .i a " d :Zhedules : <br /> WC000000A ( 04 / 92 ) WC000414 ( 07 / 90 )) W000 (142G . 442 ' 02 ) WC090606 ( 10 / 98 ) <br /> 4 . ? he premium for this policy will bt. dete .rmirn?d bY our Manuals cf Rulfs , ' <br /> Classifications , Rates and Rating fllaIls . Al '. inlCrm --- ' on required below is subject <br /> to vftrifi, cation and change by audll . <br /> Classifice . _ ons . Code Premium :lasis Rate ? el' Estimated <br /> NO _e"' tal Estinated $ 1010 of Annual <br /> F -inual Remuncration Remuneration ! Premium <br /> SEE SCHEDULE OF O ' ERAT.IONSILI <br /> r, M RR <br /> T`0ta : ?. stimated Annual Prem "_ um $ 2 , 38 . 00 .� a <br /> t . ,6 :3 <br /> Minimum Prc.. m `_ um S 50 . 00 E>: pensr-_ mon :; tant S 200 . 00 <br /> r <br /> WC 99 6 01 A co t - :. . F a b s <br />