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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 NeCI Carrier Code 21466 <br /> <br />Beri:.my Risk Admimstralors Company. LLC <br /> <br />MINNESOTA EXTRATERRITORIAL COVERAGE ENDORSEMENT <br /> <br />1. The Insured: <br /> <br />WCIP <br /> <br />Policy Number: WC-22-04-159728-03 <br />Association File Number: 3201395 <br /> <br />GNAW INC <br />dba: Centerville Liquor Barrel <br />7093 20th Ave <br />Centervil/e, 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 />1. This Insurance applies to: <br /> <br />A. An employee who regularly performs the primary duties of employment within Minnesota who receives an injury <br />while outside of Minnesota in your employ. <br /> <br />B. An employee hired in Minnesota who receives an injury while temporarily employed outside of Minnesota. <br /> <br />C. An employee who regularly performs the primary duties of employment outside of Minnesota, or is hired to perform <br />the primary duties of employment outside of Minnesota, who receives an injury within Minnesota while employed by <br />you but only if the employee chooses to forego any workers' compensation claim resulting from the injury that the <br />employee may have a right to pursue in some other state. <br /> <br />D. An employee who is a resident of Minnesota and is transferred outside the territorial limits of the United States and <br />remains your employee. <br /> <br />2. Except as specifically provided by Section 1. A-D above, this insurance does not apply to injuries occurring outside of <br />Minnesota. <br /> <br />3, No coverage is provided under this policy for claims filed in a state other than Minnesota and this policy does not pay the <br />benefits required by the laws of any state other than Minnesota. <br /> <br />IMPORTANT! IF YOU BEGIN WORK IN ANY STATE OTHER THAN MINNESOTA, YOU MUST OBTAIN INSURANCE <br />COVERAGE IN THAT STATE AND DO WHATEVER ELSE MAY BE REQUIRED UNDER THAT STATE'S LAW. THIS <br />INSURANCE DOES NOT SATISFY THE REQUIREMENTS OF THAT STATE'S WORKERS' COMPENSATION LAW. <br /> <br />All other terms and conditions of this policy remain unchanged. <br /> <br />AgencY Name and Address <br />Ross Nesbit Agencies Ine <br />Paulet Slater Agency <br />2610 University Ave W <br />St Paul, MN 55114 <br /> <br />we 99-08-09 <br />3836 639064 <br />