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POLICY NUMBER: 76 WEG BX3ZPJ <br /> NAME OF INSURER: Hartford Insurance Company of Illinois <br /> Our President and Secretary have signed this policy. Where required by law, the Information Page has been <br /> countersigned by our duly authorized representative. <br /> Kevin Barnett, Secretary A. Morris Tooker, President <br /> Includes copyright material of the National Council on Compensation Insurance, Inc. used with its permission. <br /> © 2000 National Council on Compensation Insurance, Inc. All Rights Reserved. <br /> DELAWARE: <br /> Delaware forms have been copyrighted by the Delaware Compensation Rating Bureau Inc. <br /> NEW YORK: <br /> Includes copyrighted material of the New York Compensation Insurance Rating Board, used with its permission. <br /> o 2021 New York Compensation Insurance Rating Board, all rights reserved. <br /> NORTH CAROLINA: <br /> Includes copyrighted material of the North Carolina Rate Bureau, used with its permission. <br /> PENNSYLVANIA: <br /> Pennsylvania forms have been copyrighted by the Pennsylvania Compensation Rating Bureau. <br /> Form WC 99 00 01 K Printed in U.S.A. Page 1 of 1 <br /> Process Date: 11/04/25 Policy Expiration Date: 11/04/26 <br />