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f <br /> t <br /> ( THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, <br /> PREMIUM DISCOUNT ENDORSEMENT <br /> 0 <br /> 0 <br /> C) Policy Number: 21 WB DU9567 Endorsement Number: 01 <br /> Ln Effective Date: 12 / 01 / 04 Effective hour is the same as stated on the Information Page of the policy. <br /> N Named Insured and Address: EXCHANGE CLUB CENTER FOR THE <br /> 0 <br /> t PREVENTION OF CHILD ABUSE DBA <br /> Ln PO BOX 12908 <br /> FORT PIERCE , FL 34979 <br /> N The premium for this policy and the policies, if any, listed in Item 3 of the Schedule may be eligible for a discount. This <br /> o endorsement shows your estimated discount in Item 1 or 2 of the Schedule . The final calculation of premium discount <br /> CD will be determined by our manuals and your premium basis as determined by audit. Premium subject to retrospective <br /> * rating is not subject to premium discount. <br /> -= <br /> SCHEDULE <br /> State First Next Next <br /> $5,000 $95,000 $4001Balance <br /> FL <br /> _= 00 . 0 % 3 . 5 % 5 . 0 % <br /> 7 . 0 % <br /> Other Policy Numbers : <br /> Countersigned by <br /> Authorized Representative <br /> Foran WC 00 04 06 T Printed in U.S.A. <br /> Process Date : 01 / 26 / 05 <br /> Policy Expiration Date : 12 / 01 / 05 <br />