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POLICY NUMBER: 59 WEC AC9055 <br />Our President and Secretary have signed this policy <br />countersigned by our duly authorized representative. <br />;95n�. <br />Lisa Levin, Secretary <br />Where required by law, the Information Page has been <br />C/�°'jaoulwt <br />Douglas Elliot, President <br />Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. <br />© 2000 National Council on Compensation Insurance. <br />DELAWARE: <br />Delaware forms have been copyrighted by the Delaware Compensation Rating Bureau or the Pennsylvania <br />Compensation Rating Bureau. <br />NEW JERSEY: <br />New Jersey forms have been copyrighted by the Compensation Rating and Inspection Bureau. <br />NEW YORK: <br />New York forms have been copyrighted by the New York Compensation Insurance Rating Board. <br />PENNSYLVANIA: <br />Pennsylvania forms have been copyrighted by the Pennsylvania Compensation Rating Bureau or the Delaware <br />Compensation Rating Bureau. <br />Form WC 99 00 01 1 (Signature/Copyright) <br />cF IZAManagmedDMsian <br />Jy/\'x REVIEWED & APPROVED BY.- <br />V"° <br />--� Risk janagement Analyst <br />