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' <br /> INFORMATION PAGE (Continued) Policy Number:� 22 wEc Bv6360 ~� <br /> ' <br /> . \ <br /> 3.A. Workers Compensation Insurance: Part one of the policy applies k`the Workers CnmPenxaUonLawn^1ha <br /> states listed here:mc <br />� <br /> B. Employers Liability Insurance: Part Two of the policy applies m work in each state listed in Item aA <br />� <br /> The limits nf our liability under Part Two are: <br /> Bodily injury hyAccident $100'000 each accident <br /> Bodily injury uyDisease $500,000 policy limit <br /> Bodily injury byDisease $zOo'Uoo each employee <br /> C. Other States Insurance: Part Three o{the policy applies to the states, i/any . listed here: <br /> ALL STATES EXCEPT ND, OH, WA, WY, AND <br /> sruzEs DESIGNATED IN ITEM ].A. OF THE INFORMATION PAGE. <br /> D. This policy includes these endorsements and schedule: <br /> wc UO 01 14 WC OO 03 08 wc 00 04 21c wo OV Oo 22a wc 99 O] O%B <br /> WC OO 04 14 wc OO 04 19 WC 32 O] Ozc <br /> 4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating <br /> Plans. All information i d below.is <br /> Premium Basis <br /> Classifications Total Estimated Rates Per Estimated <br /> Code Number and Annual $100 of Annual <br /> Description Remuneration Remuneration Premium <br /> 8008 90,900 2.23 2,027 <br /> STORE: CLOTHING, WEARING APPAREL OR DRY <br /> GOODS - RETAIL <br /> 8810 219,200 .25 548 <br /> CLERICAL OFFICE EMPLOYEES NOC <br /> NC - SCHEDULE MODIFICATION (0.750) (960) -644 <br /> PREMIUM ADJUSTED BY SCHEDULE MODIFICATION 1,931 <br /> TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 1,931 <br /> EXPENSE CONSTANT (0900) 250 <br /> TERRORISM (9740) 310,100 .010 31 <br /> CATASTROPHE (9741) 310,100 .010 31 <br /> TOTAL ESTIMATED ANNUAL PREMIUM 2,243 <br /> Total Estimated Annual Premium: $2,243 <br /> Deposit Premium: <br /> Policy Minimum Premium: $696 NC <br /> Interstate/intrastate Identification Number: <br /> Labor Contractors Policy Number: SIC: 5331 <br /> ProcessDate: 06/14/14' Policy Expiration Date: 08/18/15 <br />