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<br />03/14/2005 15:57 <br /> <br />5012510014 <br /> <br />THE UPS STORE 2758 <br /> <br />PAGE 03 <br /> <br />tT>rac <br /> <br />~Jlkl.Admil'Ilf.lrnM~_llC <br /> <br />Minnesota Workers' Compensation Assigned Risk Plan <br />Standard Workers' Compensation and Employers' Liability Policy <br /> <br />Contract Administrator <br />Berkley Risk Administrators Company, LLC <br />P.O. Box 59143 Minneapolis, Minnesota 55459-0143 <br />Phone (612) 766-3000 Ncel Carrier Code 21466 <br /> <br />. <br /> <br />1. The Insured: <br />Fritz Williams <br />7317 Colo..do Avenue North <br />Brooklyn Pari<, MN 55443 <br /> <br />WCIP <br /> <br />Policy Number: WC'22-04-[706B3'OO <br />Association File Number: 3176025 <br /> <br />Tax ID#: F 2001992 3 <br />UIC~: 03565587dooo <br />Policy Period: From: 2/22/20061 <br />To: 2/2212007 i <br /> <br />0"10 oIM.ilinn' ~/1/2006 I <br /> <br />Re: Policy Holder: <br />Workers' Compensation Policy #: WC-22-04-170683-00 <br /> <br />The referenced policy with the State of Minnesota Workers' Compensation Insurance Plan has been placed <br />with Berkley Risk Administrators Company. LLC for administration. The following information is required to <br />enabie uS to property administer this Workers' Compensation Coverage <br /> <br />I GENERAL INFORMATION <br /> <br />What is the legal entity for this coverage? <br /> <br />REe7J MAR <br />O:J 2008 <br /> <br />. <br /> <br />If you have any queslions, please feel free to contact me aI612-766-3607. <br />Very truly yours, <br /> <br />David D Wolfe <br />Policy Services Technician <br />Residual Market <br /> <br />Aaenev Name and Address <br />Agency Ten Insur;;ance <br />2415 Annapolis Lane Ste 111 <br />Plymouth, MN 55441 <br /> <br />. <br /> <br />APPI3 <br />1595505292 <br />