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a <br /> RED j A N 3 12005, <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: 2 0 6 05 AUDIT PERIOD * ANNUAL <br /> POLICY EFFECTIVE DATE : 12 / 01 / 04 POLICY EXPIRATION DATE : 12 / 01 / 05 <br /> r Policy Number: 21 WB DU9567 Endorsement Number: 01 HOUSING CODE : DH <br /> r-A 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 /> r <br /> Ln FEIN Number: 592094472 PRO RATA FACTOR : 1 . 000 <br /> rn <br /> D PRODUCER NAME : HARBOR INSURANCE AGENCY PRODUCER CODE : 220020 <br /> A It is agreed that the policy is amended as follows: <br /> N <br /> C:0 IN CONSIDERATION OF AN ADDITIONAL - PREMIUM OF $ 6 , 948 IT IS AGREED THAT : <br /> 0 <br /> 0 <br /> CD 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 : W0000406 <br /> Countersigned by r C loe7' <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 / 26 / 05 Policy Expiration Date: 12 / 01 / 05 <br /> ORIGINAL <br />