Laserfiche WebLink
<br />~R-10-20e3 15:47 <br /> <br />Predominate State: <br />Employers Liability: <br /> <br />DGWB <br /> <br />7148812442 P.03 <br /> <br />Name" Insured: OOW'B, ~..~)JC . <br />CUstomer In I <br />Polici'" Number: <br />Q~ote N~mber, 023850.01 <br />~an'a<tion 'Type: HE OUOT~ Effective, 01/01/03 <br /> <br />Page <br /> <br />WORKERS COMp POLICY INFORMATION Rl!:CAP <br /> <br />Employee Liability Only, <br />Admiralty Limit, <br /> <br />FEU Limit: <br /> <br />Interstate Exper Mod IO: <br />Effective Date: <br />Exper Mod: <br /> <br />CA <br />Each Accident: <br />Policy 'Limit, <br />Each Employee: <br />NO <br />Per Accidant: <br />Program Type: <br />Pcr ACCident: <br />Program Type: <br /> <br />1,000,000 <br />1,000,000 <br />1,000,000 <br /> <br />fJ - 2CJQ S -G 12 <br /> <br />1,000,000 <br />1 <br />1,000,000 <br />1 <br /> <br />Policy Minimum Premium: 750 <br />emp1 Liab Minimum PremiUm: <br />Admiralty Minimum PremiUm: <br />FELA Minimum Premium: <br /> <br />Combined Policy Premium, <br />NJ Premium: <br /> <br />ExeCUtive Officers: <br />Employee Leasing: <br />Deposit Factor: <br />Installments: <br /> <br />St.ate: <br />Rate Iiode: <br />Retro Plan: <br />Intra Exper Iiod ID: <br />Effecti"e Date: <br />E:xper Mod: <br />Rate Revision Date: <br />Oev Revision Date: <br />Premium DiScount <br />First: <br />Next: <br />Next, <br />Balance: <br />Commission Expense: <br />Other Expenses: <br />Commission (Norm): <br />Prem Subj to Corom. <br /> <br />N"O <br />NO <br /> <br />WORKERS COMP STATE INFORMATION Rl!:CAP <br /> <br />CA <br />G <br />NO <br />00000000 <br />01/01/03 <br />1. 00 (ACTUAL) <br />01/01/03 <br />01/01/03 <br /> <br />NIL <br />.109 <br />.126 <br />.144 <br />.06 <br />.0504 <br />o <br />54,965 <br /> <br />(5000) <br />(95000 ) <br />(400000) <br />(BALAN"CS) <br /> <br />S 1'0 I,'ORM <br />:APPROVED A <br /> <br />~~ <br />/f.. . c <br />launl ~.'hel ',ly <br />Dep"!, t Il} !\lfflfney <br /> <br />TOTAL P. 03 <br />