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<br />t;)rac <br /> <br />Minnesota Workers' Compensation Assigned Risk Plan <br />Standard Workers' Compensation and Employers' Liability Policy <br />Contract Administrator <br />Berkley Risk Administrators Company, LLC <br />P.O. Box 59143 Minneapolis, Minnesota 55459-0143 <br />Phone (612) 766-3000 NCCl Carrier Code 21466 <br />INFORMATION PAGE <br /> <br />Bcri<ley RisI< IIOrruno.aIcI1l Coiwany. LLC <br /> <br />Renewal Of No. WC-22-04-159728-02 <br /> <br />1. The Insured: <br />GNAW INC <br />dba: Centerville LIquor Barrel <br />7093 20th Ave <br />Centerville, MN 55038 <br /> <br />WCIP <br /> <br />Policy Number: WC-22-04-15972S-Q3 <br />Association File Number: 3201395 <br /> <br />Other workplaces not shown above: <br /> <br />Tax 10#: F 830385468 <br />UIC#: 068707550000 <br />Date of Mailing: 11/2/2007 <br />~ Individual C Partnership <br />c2<~ Corporation =:J Other <br /> <br />2. The policy period is from 12:01 a.m.1/6f2008 to 12:01 a.m.1/6f2009 at the insured's mailing address. <br />3.A. Workers' Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the states listed here: <br />MN <br /> <br />B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A <br />The limits of our liability under Part Two are: Bodily Injury By Accident $100,000 each accident. <br />Bodily Injury By Disease $500,000 policy limit. <br />Bodily Injury By Disease $100,000 each employee. <br />C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: <br /> <br />D. This policy includes these endorsements and schedules: <br />WC000403 WC000414 WC000419 WC000422 WC220000 WC220301 WC220601D WC220620 WC990001A WC990809 <br /> <br />4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. <br />All information required below is subject 10 verification and change by audit. <br /> <br />PREMIUM BASIS RATES ENTRIES IN THIS ITEM, EXCEPT AS SPECIFICALLY PROVIDED ESTIMATED <br />ESTiI'MTED TOTAL PER $100 OF CODE ELSEWHERE IN THIS CONTRACT; DO NOT MODIFY ANY OF ANNUAL <br />ANNUAL REMUNERATION NO. THE OTHER PROVISIONS OF THIS POLICY. PREMIUM <br />REMIINERl1,T!ON <br /> Manual Premium $106.00 <br />See Schedule Standard Premium $106.00 <br /> Merit Rating (B) 0.67 ($35.00) <br />Minimum Premium: $226.00 Adjusted Standard Premium $71.00 <br /> Expense Constant $170.00 <br /> Foreign Terrorism Stat Code 9740 $1.00 <br /> Special Compo Fund Surcharge Stat Code 0174 1.029 $3.00 <br /> Policy Total Estimated Cost $245.00 <br /> Net Deposit Premium Required $245.00 <br />Aqency Name and Address Premium Paid to Date ($245.00) <br /> Total Premium Due $0.00 <br />Ross Nesbit Agencies Inc <br />Paulet Slater Agency <br />2610 University Ave W <br />St Paul, MN 55114 <br /> <br />DATE: 11/2/2007 <br /> <br />Signature: <br /> <br />~~ <br /> <br />~ "< .p'...nte"~. <br /> <br />Includes copyright material of the National Council on Compensation Insurance used with its pennission. <br />@1983 .@ 1991 National Council Compensation Insurance <br /> <br />we 99-00-01 <br />3836 639064 <br />