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i2ub EGD <br /> THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, <br /> CHANGE IN INFORMATION PAGE <br /> INSURER : HARTFORD INSURANCE COMPANY OF THE MIDWEST <br /> NCCI Company Number: 20605 AUDIT PERIOD : ANNUAL <br /> POLICY EFFECTIVE DATE : 12 / 01 / 04 POLICY EXPIRATION DATE : 12 / 01 / 05 <br /> E� Policy Number: 21 WB DU9567 Endorsement Number: 01 HOUSING CODE : DH <br /> T-i Effective Date: 12 / 01 / 04 Effective hour is the same as stated in the Information Page of the policy. <br /> C> Named Insured and Address : EXCHANGE CLUB CENTER FOR THE <br /> PREVENTION OF CHILD ABUSE DBA <br /> Ln PO BOX 12908 <br /> o FORT PIERCE , FL 34979 <br /> Ln FEIN Number: 592094472 PRO RATA FACTOR : 1 . 000 <br /> rn <br /> PRODUCER NAME : HARBOR INSURANCE A <br /> A GENCY PRODUCER CODE : 220020 <br /> It is agreed that the policy is amended as follows : <br /> N <br /> C) IN CONSIDERATION OF AN ADDITIONAL - PREMIUM OF $ 6 , 948 IT IS AGREED THAT : <br /> 0 <br /> 0 <br /> C) THIS ENDORSEMENT REFLECTS ADJUSTMENT IN PREMIUM BASIS DUE TO <br /> * RECENT AUDIT COMPLETED FOR THIS ` INSURED . <br /> ( A ) POLICY IS AMENDED TO CHANGE PAYROLL ON CLASS 8861 FOR INSD 01 <br /> ST 09 LOC 01 <br /> FORM NUMBERS OF ENDORSEMENTS REVISED AT ENDORSEMENT <br /> ISSUE : WC000406 <br /> Countersigned by <br /> Aut orized Representative <br /> Form WC 99 00 06 A (1 ) Printed in U . S.A. Pagel ( CONTINUED ON NEXT PAGE ) <br /> Process Date: 01 / 2 6 / 0 5 Policy Expiration Date: 12 / 01 / 05 <br /> ORIGINAL <br />