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i <br /> 0 0 (Policy Provisions : WC 0 0 0 0 0 0 A ) <br /> 77 <br /> GD INFORMATION PAGE <br /> wEc WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY <br /> INSURER : HARTFORD UNDERWRITERS INSURANCE COMPANY <br /> HARTFORD PLAZA , HARTFORD , CONNECTICUT 06115 <br /> NCCI Company Number. ln� THE <br /> Company Code : 6 HARTFORD <br /> 0 <br /> Suffix <br /> C) LARS RENEWAL <br /> o POLICY NUMBER : <br /> 91 WPr Gn:77nn 010 <br /> C) Previous Policy Number: <br /> r� HOUSING CODE : DV <br /> 0 1 . Named Insured and Mailing Address : INDIAN RIVER COUNTY HEALTHY <br /> CN ( No . , Street, Town , State , Zip Code) ( SEE ENDT ) <br /> 0 <br /> 0 <br /> Ln 1603 10TH AVENUE <br /> * FEIN Number. 650363222 VERO BEACH , FL 32960 <br /> State Identification Number(s): <br /> The Named Insured is: CORPORATION <br /> Business of Named Insured : CIVIC ORGANIZATION <br /> Other workplaces not shown above: 1603 10TH AVENUE VERO BEACH , FL 32960 <br /> 2. Policy Period : From 05 / 03 / 03 To 05 / 03 / 04 <br /> 12:01 a .m. , Standard time at the insured's mailing address . <br /> Producer's Name : SID BANACK INSURANCE / SCIC <br /> P . 0 . BOX 29611 <br /> CHARLOTTE , NC 28229 <br /> Producer's Code : 227667 <br /> Issuing Office : THE HARTFORD <br /> 8711 UNIVERSITY EAST DRIVE <br /> CHARLOTTE NC 28213 <br /> ( 866 ) 467 - 8730 <br /> Total Estimated Annual Premium : $ 916 <br /> Deposit Premium : <br /> Policy Minimum Premium : $ 236 FL <br /> Audit Period: ANNUAL Installment Tenn : <br /> The policy is not binding unless countersigned by our authorized representative . <br /> Authorized Representative <br /> Foran WC 00 00 01 A (1 ) Printed in U .S .A. Page 1 (Continued on next page) <br /> Process Date : 03 / 08 / 03 Policy Expiration Date : 05 / 03 / 04 <br /> ORIGINAL <br />