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JOGPSNBUJPO!QBHF!)Dpoujovfe* <br />Qpmjdz!Ovncfs;6 WEG B3P <br />4/B/!Xpslfst!Dpnqfotbujpo!Jotvsbodf;Part one of te policy applies to te Worers Compensation Law of te states <br />listed ereTSEE EDORSEMET - WC 99 03 6 <br />C/!Fnqmpzfst!Mjbcjmjuz!Jotvsbodf;Part Two of te policy applies to wor in eac state listed in Item 3.A. <br />Te limits of or liaility nder Part Two are <br />Cpejmz!jokvsz!cz!Bddjefou1,000,000 fbdi!bddjefou <br />Cpejmz!jokvsz!cz!Ejtfbtf1,000,000 qpmjdz!mjnju <br />Cpejmz!jokvsz!cz!Ejtfbtf1,000,000 fbdi!fnqmpzff <br />D/!Puifs!Tubuft!Jotvsbodf;Part Tree of te policy applies to te states, if any , listed ere <br />ALL STATES ECEPT ORT DAOTA, OIO, WASIGTO, WYOMIG, .S.TERRITORIES AD STATES <br />DESIGATED I ITEM 3.A. OF TE IFORMATIO PAGE. <br />E/!Uijt!qpmjdz!jodmveft!uiftf!foepstfnfout!boe!tdifevmf; <br />SEE EDORSEMET-WC 99 03 68 <br />5/Uif!qsfnjvn!gps!uijt!qpmjdz!xjmm!cf!efufsnjofe!cz!pvs!Nbovbmt!pg!Svmft-!Dmbttjgjdbujpot-!Sbuft!boe!Sbujoh <br />Qmbot/Bmm!jogpsnbujpo!sfrvjsfe!cfmpx!jt!tvckfdu!up!wfsjgjdbujpo!boe!dibohf!cz!bveju/ <br />Qsfnjvn!Cbtjt <br />DmbttjgjdbujpotUpubm!FtujnbufeSbuft!QfsFtujnbufe <br />Dpef!Ovncfs!boeBoovbm%211!pgBoovbm <br />EftdsjqujpoSfnvofsbujpoSfnvofsbujpoQsfnjvn <br />Total Standard Premim,084 <br />Premim Discont-4 <br />Epense Constant200 <br />Terrorism Ris Insrance Program Reatoriation Act Disclosre Endorsement68 <br />Catastrope Oter Tan Certified Acts Of Terrorism31 <br />Estimated Annal Premim efore Srcarges,39 <br />Total Estimated Srcarges204 <br />See te attaced Scedles of Operations for Location and State Leel Premim Information <br />Upubm!Ftujnbufe!Boovbm!Qsfnjvn;,83 <br />Efqptju!Qsfnjvn; <br />Qpmjdz!Njojnvn!Qsfnjvn; <br />600CA Incldes Increased Limit Min. Prem. <br />Joufstubuf0Jousbtubuf!Jefoujgjdbujpo!Ovncfs;Refer to Scedle of Operations <br />AICS 13940 <br />Mbcps!Dpousbdupst!Qpmjdz!Ovncfs;TJD;991 <br />Gpsn!XD!11!11!12!B)2*Printed in .S.A.Qbhf!3 <br />Qspdftt!Ebuf;11/04/2Qpmjdz!Fyqjsbujpo!Ebuf;11/04/26 <br /> <br />