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WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY <br />SURCHARGE QVERFLOW PAGE <br />PAGE NUU; 01 23-1229 FAC1 <br />POLICY NO. 92-GA-J324-6 COVERAGE IS PROVIDED BY <br />STATE FARM FIRE NO CASUALTY COMPANY <br />PO Box 853925, Richardson TX 75085-3925 <br />STATE ASSESSMENT <br />$ <br />18,00 <br />LBR ENFMT COMPL <br />ASMT <br />$ <br />4.00 <br />OCC SAFETY HLTH <br />FUND <br />$ <br />5,000 <br />SUNINNUMBBENEFIT <br />ASMT <br />$ <br />1.00 <br />REVIEWED & APPROVED <br />By RISK MANAGEMENT Divi510N <br />OCT422019� <br />+FAN4 R. VILI AREAL <br />PREPARED 05/20/2019 WC990003(ED 3-11) <br />