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LL�fi <br /> COMMERCE AND INDUSTRY INSURANCE COMPANY 76119 - 0000 WC - 930 - 64 - 45 <br /> 15172 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> 013 - 82 - 0905 - 00 <br /> • . NEW YORK <br /> ST . PETER ' S ACADEMY CHARTER SCHOOL <br /> 4250 38TH AVE � � Member Companies of <br /> VERO BEACH , FL 32697 - 0000 American International Group <br /> EXECUTIVE OFFICES : <br /> 70 PINE STREET , NEW YORK, N . Y. 10270 <br /> SEE NAME AND ADDRESS SCHEDULE - WC990610 <br /> I . o # 0 104 10 FL UI # : Hatcher Insurance Inc . . . <br /> PO Box 540689 <br /> WORKERS COMPENSATION AND EMPLOYERS Orlando , FL 32854 <br /> LIABILITY POLICY INFORMATION PAGE <br /> INSURED IS PREVIOUS POLICY NUMBER <br /> CORPORATION RENEWAL 007754294 <br /> OTHER WORKPLACES NOT SHOWN ABOVE : SEE NAME AND ADDRESS SCHEDULE - WC 0610 <br /> ITEM 2 POLICY PERIOD 12:01 A. M. standard time at the insured 's <br /> mailing address FROM 09 / 17 / 05 TO 09 / 17 / 06 <br /> ITEM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states <br /> listed <br /> here : <br /> FL <br /> B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item <br /> 3 .A . <br /> The limits of our liability under Part Two are: <br /> Bodily Injury by Accident $ 100 , 000 each accident <br /> Bodily Injury by Disease $ 500 , 000 policy limit <br /> Bodily Injury by Disease $ 100 , 000 each employee <br /> C. Other States Insurance: Part Three of the policy applies to the states , if any, listed here: <br /> AK AL AR AZ CO CT DC DE GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC NE NH NJ <br /> NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI <br /> ITEM 4 The premium for this policy will be determined by our Manuals of Rules , Classifications , Rates and Rating Plans <br />. <br /> All information required below is subject to verification and change by audit. <br /> Estimated Total Rate Per Estimated <br /> Classifications Code Number Remuneration $ 100 OF Re- Premium <br /> Annual 11 3 Year muneration Annual 3 Year <br /> SEE EXTENSION OF INFORMATION PAGE - WC7754 <br /> EXPENSE CONSTANT ( EXCEPT WHERE APPLICABLE BY STATE) $ 200 FL <br /> MINIMUM PREMIUM $ 1 9000 FL TOTAL ESTIMATED PREMIUM $ 9Y656 <br /> If indicated below, interim adjustments of premium shall be made : <br /> Semi -Annually Quarterly Monthly DEPOSIT PREMIUM <br /> ENDORSEMENTS ( FORM NUMBER ) SEE ATTACHED FORM SCHEDULE - WC990612 <br /> 07 / 25 / 05 PARSIPPANY 82 <br /> Issue Date Issuing Office Authorized Representative wC 00 00 01 <br /> 39967 <br /> INSURED ' S COPY <br />