Laserfiche WebLink
WORKERS COMPENSATION AND E%OYERS LIABILITY POLICY <br />INFOR23»1229_FAC1 <br />GE <br />POLICY NO 92-GA-J3z4-6 SOVE AGE IS PR6VI1U D BY <br />REPLACES N0, 92-EW-•f�1768-i TATP FARM FIR A D CASUALTY CVpMPANY <br />PO Box 653925, Richardson TX 75g85-3925 <br />NCCI CARRIER CODE NO, 14842 <br />i, NAMED INSIYRED & MAILING ADDRESS <br />S(A��NIIppVA Upp I FEIN 953083493 <br />SANNAXANASC U DEL 92703�U168 SANTAI�IATCAANABL D STa 214A <br />INSURED IS AN INDIVIDUAL <br />COPYRIGHT 1987 NATIONAL COUNCIL ON COMPENSATION INSURANCE <br />2. ATETHOELINSUREbl6DMAIL.INGMAgl7RES52018 TOKOQ7/Cli:1A/ :fl 0 12:01 A.M. STANDARD TIME <br />3A. WORKERS GQM�PONSAfIbN LAWUOF�TNE SAAIEONE 06TH POLICCAAPPLICS TO THE <br />B. UTO <br />NIIB5PR�0ARTCH STAIT6ERS YLISO D INNJU R YTAgCeDEW I- I 'SO0DY00Rpkl HILCCIDENT <br />BODILY INJURY BY DiISIEAS $ <br />t,D440;0p0� EACH ACCIDENT <br />C. EXCEPTShI TCMTINNUORAQFIEIRPARWATHWlUC WY ANDS UE S LISTEDSINU3ALL STATES <br />D. <br />C436CY0431DT004060 RSC0404NDWC0043*' WCOODOOOCW000AWC00AW0006 <br />*EFFECTIVE 07/01/19 <br />4, THE <br />PREMIUM IOR TH ISPOLICYYTESILMDBE <br />DETERPLANDS.BA <br />MM <br />OLURJANUALS <br />OF <br />_---' ____ <br />REQ <br />M ED BELOW IS SUBJECT TQ <br />VERIFICATION AND CIIANIGE BY <br />AUDIT, <br />4Ar!(7Y______ __ ________________"7ALME3MIMAIS' <br />AN--REMD�IE100 <br />LSXIUALTCD <br />QIlEuNQS <br />OLASSIFII;ATIONS <br />NUAL REMUNERATION <br />PION <br />PREMIUM <br />8810ICAL <br />4 <br />-- <br />_ H~176,800 <br />.40 p <br />- 707 <br />CLEROFFICE EMPLOYEESV- MOC4Y <br />8868 V1� <br />ADU7(L7MO61L6RSGMODDLSS- pIPOFESSORS NOT <br />TEACHERS OR PRUFESSIUNAL EMPLOYEES <br />EC.MP1-0YERSULLIABIILITYOPIMNT$EASED <br />TERRORISM 9740 <br />44,200 <br />REVIEWED & APP <br />By Rizk MANnCLMrNT <br />221.000 <br />77 <br />.03 <br />340 <br />115 <br />66 <br />MINIMUM PREMIUM $ 500 CALIFORNIA TOTAL ESTIMATED ANNUAL PREMIUM $ 1,228 <br />PREMIUM ADJUSTMENT PERIOD SHALL BE ANNUAL STATE DEPOSITPREMIUM <br />$ 1A228 <br />FDSUCHARGE.00 <br />SEE SURCHARGE OVERFLOW PAGE <br />PREPARED 05/20/2019 <br />WC 00 00 01 04-84 COUNTERSIONE <br />