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<br />.&rac <br /> <br />1lorIIoy1W<_~.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 NCCI Carrier Code 21466 <br /> <br />Sched ule for MN <br /> <br />Renewal Of No. WC.22-()4-159728-G2 <br />1. The Insured: <br /> <br />WCIP <br /> <br />Policy Number: WC.22-G4-159728-G3 <br />Association File Number: 3201395 <br /> <br />GNAW INC <br />dba: Centervllle Liquor Barrel <br />7093 20th Ave <br />Centervllle, MN 55038 <br /> <br />Tax 10#: F 830385468 <br />UIC #: 068707550000 <br />Policy Period: From: 1/6/2008 <br />To: 1/6/2009 <br />Endorsement Eff. Date: 1/6/2008 <br />Date of Mailing: 11/212007 <br /> <br />PREMIUM BASIS RATES ENTRIES IN THIS ITEM, EXCEPT AS SPECIFICALLY PROVIDED ESTIMATED <br />ESTIMATED TOTAL ANNUAL PER $100 OF CLASS ELSEWHERE IN THIS CONTRACT; DO NOT MODIFY ANY OF ANNUAL <br />REMUNERATION REMUNERATION CODE THE OTHER PROVISIONS OF THIS POLICY. PREMIUM <br /> GNAW INC <br /> 7093 20th Ave <br /> Centerville MN. 55038 <br />$4,750 2.23 8017 STORE RISKS - RETAIL NOC $106 <br /> <br />Manual Premium <br />Short Rate <br />Increased Limits <br />EXperience Modification <br />Merit Rating <br />MCPAP (Obsolete) <br />Standard Premium <br /> <br />$106.00 <br />$0.00 <br />$0.00 <br />$0.00 <br />$0.00 <br />$0.00 <br />$106.00 <br /> <br />Aaencv Name and Address <br />Ross Nesbit Agencies Inc <br />Paulet Slater Agency <br />2610 University Ave W <br />5t Paul, MN 55114 <br /> <br />WC990001A <br />