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Insured Copy <br /> <br /> <br /> Chubb Group of Insurance Companies <br />436 Walnut Street, Philadelphia, PA 19106 <br /> <br /> <br />Item 1. Name & Mailing Address of the Insured <br />ECS SOUTHEAST, LLC <br />14030 THUNDERBOLT PLACE <br />SUITE 500 <br />CHANTILLY, VA 20151 <br /> <br />FEIN 20-2806940 <br />INFORMATION PAGE <br />WORKERS COMPENSATION AND <br />EMPLOYERS LIABILITY POLICY <br /> <br />Issued by Bankers Standard Insurance <br />Company <br />a stock insurance company <br />incorporated in PENNSYLVANIA <br /> <br />N.C.C.I. Carrier Code 20206 <br />TEL#: # of EMP: Policy Number (25) 7176-41-67 <br />UI#: <br />Insured is: Limited Liability Partnership <br />Name & Address of the Producer Previous Policy Number (24) 7176-41-67 <br />ARTHUR J GALLAGHER RISK MANAGEMENT <br />SERVICES LLC <br />14026 THUNDERBOLT DRIVE <br />SUITE 200 <br />CHANTILLY 20151 <br /> <br />Producer Number 0050141 <br />OTHER WORK PLACES NOT SHOWN ABOVE - SEE ATTACHED EXTENSION OF INFORMATION PAGE <br />Item 2. POLICY PERIOD <br />12:01 A.M. standard time at the insured's mailing address FROM 12/01/24 TO 12/01/25 <br />Item 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law <br />of the states listed here: AL, GA, HI, KY, LA, MS, NC, SC, TN <br />B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in Item <br />3A. The limits of our liability under Part Two are: <br />Bodily Injury by Accident $ 1,000,000 each accident <br />Bodily Injury by Disease $ 1,000,000 policy limit <br />Bodily Injury by Disease $ 1,000,000 each employee <br /> <br />C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: All States, <br />Except states designated in Item 3.A and ND, OH, WA, WY <br /> <br />D. Endorsements (Form No.) Refer To Extension of Information Page "List of Endorsements & Schedules" <br />Item 4. The Premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating <br />Plans. All information required below is subject to verification and change by audit. <br />Refer to Extension of Information Page <br /> <br />Minimum Premium: $ Total Estimated Premium: <br />Minimum Premium State: MISSISSIPPI Total State Surcharges: <br />Expense Constant: MISSISSIPPI ($250 INCL) Total Estimated Charge: <br />Premium Adjustment Period: AT EXPIRATION Deposit Amount: <br /> <br /> <br />CHUBB GROUP OF INSURANCE COMPANIES: <br />1001 G STREET NW <br />SUITE 400 <br />WASHINGTON, DC 20001-1401 <br /> <br />Authorized Representative and Date Signed <br /> <br /> <br /> <br />Issue Date: 11/08/24 <br />Form WC 00 00 01A (Rev. 5-88) Includes copyright material of the National Council on Compensation Insurance,used <br />with its permission. Copyright 1987, National Council on Compensation Insurance <br /> <br /> <br />11/08/24 <br />Docusign Envelope ID: 6A9D5D34-5CDF-4B61-99A9-F61CBCEDBF5E