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A FLORIDA WORKERS' COMPENSATION <br /> JOINT UNDERWRITING ASSOCIATION, INC. WORKERS COMPENSATION <br /> AND <br /> EMPLOYERS LIABILITY POLICY <br /> EXTENSION OF INFO PAGE — SCHEDULE WC 00 00 01 ( A ) <br /> POLICY NUMBER : ( 6FR1 3UB - 421 1 B59 - 0 - 05 ) <br /> INSURER : FLORIDA W . C . JUA <br /> 80179 — FL <br /> INSURED ' S NAME : PROJECT HOPE INC <br /> PREMIUM BASIS <br /> ESTIMATED RATES ESTIMATED <br /> TOTAL ANNUAL PER $ 100 OF ANNUAL <br /> CLASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM <br /> LOCATION 001 01 <br /> FEIN 593449353 ENTITY CD 001 <br /> PROJECT HOPE INC <br /> 3790 45TH ST <br /> VERO BEACH , FL 32967 <br /> COLLEGE OR SCHOOL : <br /> PROFESSIONAL EMPLOYEES & <br /> CLERICAL 8868 136000 1 . 00 1360 <br /> o� <br /> o� <br /> 0� <br /> 0 <br /> 0 <br /> 0� <br /> m <br /> -- <br /> . . . . . . . . . . <br /> EXPERIENCE MODIFICATION : NONE MODIFIED PREMIUM $ NONE <br /> 0 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 1360 <br /> TIER 1 SURCHARGE 400 <br /> EXPENSE CONSTANT ( 0900 ) 200 <br /> TERRORISM RISK INS ACT 2002 ( 9740 ) 41 <br /> • ASSIGNED RISK FLAT SURCHARGE ( 9601 ) 475 <br /> FWCJUA MANDATORY DEPOSIT 1238 <br /> TOTAL ESTIMATED PREMIUM 3714 <br /> DEPOSIT AMOUNT DUE 3714 <br /> DATE OF ISSUE : 06 - 10 - 05 RM ST ASSIGN : FL SCHEDULE NO : 1 OF LAST <br /> 009380 <br />