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Fl� 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 : ( GFR1 3UB - 7988B04 - 4 - 05 ) <br /> INSURER : FLORIDA W . C . JUA <br /> 80179 — FL <br /> INSURED ' S NAME : HOMELESS FAMILY CENTER INC <br /> RATE BUREAU ID : 091317621 <br /> EXP . MOD . EFFECTIVE DATE : 07 - 29 - 05 <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 593129752 ENTITY CD 001 <br /> HOMELESS FAMILY CENTER INC <br /> 715 4TH PLACE <br /> VERO BEACH , FL 32962 <br /> CHARITABLE OR WELFARE <br /> ORGANIZATION — PROFESSIONAL <br /> EMPLOYEES & CLERICAL 8861 337922 1 . 68 5677 <br /> a <br /> WELFARE OR CHARITABLE <br /> ORGANIZATION : ALL OTHER <br /> EMPLOYEES & DRIVERS 9110 22347 9 . 38 2096 <br /> LOCATION 002 01 <br /> FEIN 593129752 ENTITY CD 001 <br /> 0 <br /> HOMELESS FAMILY CENTER INC <br /> 720 4TH STREET <br /> VERO BEACH , FL 32962 <br /> N <br /> m <br /> O <br /> O� <br /> O <br /> W� <br /> a � <br /> DATE OF ISSUE : 08 - 01 - 05 SR ST ASSIGN : FL SCHEDULE NO : 1 OF MORE <br /> 008175 <br />