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<br />tirac <br /> <br />Iler'dIyPiok~~.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 NCel Carrier Code 21466 <br /> <br />NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT <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: 1/612008 <br />To: 1/612009 <br />Endorsement Eff. Date: 11612008 <br />Date of Mailing: 11/212007 <br /> <br />Experience rating is mandatory for all eligible Insureds. The experience rating modification factor, if any, applicable <br />to this policy, may change if there is a change in your ownership or in that of one or more of the entities eligible to be <br />com bined with you for experience rating purposes. Change in ownership includes sales, purchases, other transfers, <br />mergers, consolidations, dissolutions. formations of a new entity and other changes provided for in the applicable <br />experience rating plan manual. <br /> <br />You must report any change in ownership to us in writing within 90 days of such change. Failure to report such changes <br />within this period may result in revision of the experience rating modification factor used to determine your premium. <br /> <br />All other terms and conditions of this policy remain unchanged. <br /> <br />Agencv Name and Address <br />Ross Nesbit Agencies Inc <br />Paulet Slater Agency <br />2610 University Ave W <br />St Paul, MN 55114 <br /> <br />WC 00-04-14 <br />3836 639064 <br />