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NOV - 11 - 2004 10 : 33 AM CULrURAL . COUNCIL . IRC 77277e34e3 P003 <br /> WORMS COMPENSATION AND 3MPL(',--YERS _ TABILITY INSURANCE POLICY WC 99 06 01 A <br /> REISSUE INFORMATION PAGE RENEWAL AGREEMENT <br /> Insurer ; Produce : : Agent # 722 <br /> Harbor Specia _ ty Insurance Company Sid Banack Insurance <br /> C / C Unisource Administrators , I . b , 0 . Box 130 <br /> 5951 Cattieridge Blvd . , Suite 2CO Vero Beach , FL 32961 <br /> Sarasota , FL 34232 <br /> ( Carrier Code. : 35270 ) 024 Car _• '_ et• Policy 7 : 0 ) 9000004981203 <br /> Carrier Pr _ or Poliny # : 09900000498 .1, 202 <br /> '. . The Insured : Cultural of Tn. dian Rive .r County , <br /> Type of Business : Cc .rporation <br /> Mailing Address : 2145 '_ 4 Ave 811 <br /> Vero Beac .7 , 1710 32960 <br /> Other ts, rkplaces not shown abovs , Fein : 593299133 <br /> NO OTHER WORK ?LACES FOR ^. HIS POLICY Risk ID : <br /> 2 . The. IV <br /> olicy period is from 12 : 01 f . m , on L / 20 / 2003 to 12 : 01 a . m . on 17 / 20 ' 2004 <br /> s - the in <br /> sured ' s mailing acdress . <br /> A . Workers Compensatton. Insurance Part One of the pelicy applies - o the Workers <br /> Compensation L. aw of : he states listed here : <br /> FL <br /> 1' . Cmployers Liability Incurs: nce : Pa .� t Two of _ he policy app _ ies to work. in each <br /> state listed in Item 3 . A . The lir: ' . ., of a : r li, abi, l, ity under Part Two <br /> are : <br /> Bndi ? y Injury by Accident $ 1 ; 01000 each accident <br /> Bodily Injury by Disease $ 500 , 000 policy lima = <br /> Bodily Injury by Disease $_ _ 100 . 000 each emiloyr;: e% <br /> C . Other States Insurance : <br /> D . This poli , y .in.r? ude. s these endorsen; ert .1 al", d s � hecules : <br /> WC000000A ( 04 / 92 ) WC000414 ( 07 / 90 ) WCOOU420 , '12002 ) WC090606 ( 10 / 98 ) <br /> 4 . ?. he premium for this policy will b+ determined i; i our Manuals of RuIeS , <br /> Classifications , Rates and Rating Flans , Al .. i211Crmat. ' on .r. equi = ed below is subject <br /> to verification and change by auall, . <br /> CIass1ficet '_ ans Code Premium Iasis Rate ? er Estimated <br /> No . 'ctal Estimated <br /> $ 10i, of Annual <br /> Innual. Remuneration Remuneration Premium <br /> SEE SCF: EDULE OF 07ERATTONS <br /> Lota : 7stimated Annual Prem "_ um <br /> Minimum Premum S 50 , 00rrpensr. " oP.. :; tar, 3 240 . 00 <br /> WC 99 'i f; 01 A Ccu : : t . d by ✓,!JAI:Rt <br />