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BRIDGEFIELD <br /> EMPLOYERS INSURANCE <br /> COMPANY <br /> A Stock Insurer • P. O. Box 988 a Lakeland, FL 33802-0988 <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE <br /> Carrier code 31267 Policy number 830 - 28580 <br /> Item 1 , Insured <br /> Prior policy number 0830-28580 <br /> Name Hibiscus Childrens Center, Inc. RISK I .D . 097428905 <br /> and 2400 S .E. Dixie Highway <br /> Address Jensen Beach, FL 34957 _ Individual X Corporation <br /> Partnership _ Subchapter "S" <br /> Other <br /> Other workplaces not shown above : <br /> FEIN 59-2632361 <br /> SEE EXTENSION OF INFORMATION PAGE <br /> Item 2. Policy period <br /> From 2/22/03 To 2/22/04 12 : 01 a. m . standard time at the address of the insured as stated herein . <br /> Item 3 . Coverage <br /> A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed <br /> here: Florida <br /> B. Employers Liability Insurance : Part Two of the policy applies to work in each state listed in Item 3 .A. The limits <br /> of our <br /> liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident <br /> Bodily Injury by Disease $ 500,000 each employee <br /> Bodily Injury by Disease $ 500,000 policy limit <br /> C . Other States Insurance: Part Three of the policy applies to the states, if any, listed here: <br /> D . This policy includes these endorsements and schedules: See Schedule <br /> Item 4 . Premium <br /> The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All <br /> information required below is subject to verification and change by audit. <br /> Premium Basis: <br /> Classnlcations Total Estimated RabPer $10o EstImated <br /> Code No, Annual Remuneration of Remuneration Annual Premium <br /> See Extension of Information Page <br /> Total Estimated Annual Premium $ 50, 162 . 06 <br /> Minimum Premium $ .00 Expense Constant $ 200 . 00 <br /> This policy, including all endorsements issued there ith , is hereby <br /> Countersigned by L nd� �` 'I Date 12/ 19/02 <br /> 2112 R. V. Johnson Agency <br /> NAI Date Prepared : 12/ 19/02 <br /> (5 0000 t)1A Includes copyright material of the National Council on Compensation Insurance. Used with its permission. <br /> BEIC00014 STATE REV 9/02 ( 02 -521 ) <br /> 01987 National Council on Compensation Insurance <br />