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<br />tirac <br /> <br />IlorIIoy Ri. MnriI_ Comporr,.lLC <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 NCCI Carrier Code 21466 <br />MINNESOTA ENTITY AND ADDRESS SCHEDULE <br /> <br />1. The Insured: <br /> <br />WCIP <br /> <br />Policy Number: WC-22-04-159728-o3 <br />Association File Number: 3201395 <br /> <br />GNAW INC <br />dba: Centervllle Liquor Barrel <br />7093 20th Ave <br />Centerville, MN 55038 <br /> <br />Tax 10#: F 830385468 <br />UIC #: 068707550000 <br />Policy Period: From: 1/6/2008 <br />To: 1/612009 <br />Endorsement Eff. Date: 1/6/2008 <br />Date of Mailing: 111212007 <br /> <br />Entity Information: <br /> <br />Insured Name: GNAW INC <br />FederallD Number: F - 830385468 <br />UIC Number. 068707550000 <br />dba: Centerville Liquor Barrel <br /> <br />o Individual <br />[K] Corporation <br /> <br />o Partnership <br />o Other <br /> <br />7093 20th Ave <br />Centerville, MN 55038 <br /> <br />Aaencv Name and Address <br />Ross Nesbit Agencies Inc <br />Paulet Slater Agency <br />2610 University Ave W <br />St Paul. MN 55114 <br /> <br />WC220620 <br />3836 639064 <br />