Laserfiche WebLink
<br />1. The Insured: <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 />FOREIGN TERRORISM PREMIUM ENDORSEMENT <br /> <br />Page 1 of 1 <br /> <br />welP Po/icy Number: WC-22-04-159728-03 <br />Association File Number: 3201395 <br /> <br />li>rac <br /> <br />Berney Risk Administrators Company. LtC <br /> <br />GNAW INC <br />dba: Centerville Liquor Barrel <br />7093 20th Ave <br />Centerville, MN 55038 <br /> <br />Tax 10#: F 830385468 <br />ule #: 068707550000 <br />Policy Period: From: 1/6/2008 <br />To: 1/6/2009 <br />Endorsement Eff. Date: 1/6/2008 <br />Date of Mailing: 11/2/2007 <br /> <br />This endorsement is notification that your insurance carrier is charging premium for losses that may occur in the event of an act <br />of foreign terrorism <br /> <br />Your policy provides coverage for workers compensation losses caused by acts of foreign terrorism, including workers <br />compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, definitions, <br />exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations. <br /> <br />For purposes of this endorsement, an "act of foreign terrorism" is defined as: <br />a. Any act that is violent or dangerous to human life, property or infrastructure; and <br />b. The act has been committed by an individual or individuals acting on behalf of any foreign person or foreign <br />interest, as part of an effort to coerce the civilian population of the United States or to influence the policy or <br />affect the conduct of the United States Government by coercion. <br /> <br />The premium charge for the coverage your policy provides for workers compensation losses caused by an act of foreign <br />terrorism is shown in Item 4 of the Information Page or in the Schedule below. <br /> <br />Schedule <br /> <br />Rate per $100 of <br />State Remuneration <br /> <br />MN 0.02 <br /> <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br /> <br />Aqency Name and Address <br />Ross Nesbit Agencies Jnc <br />Paulet Slater Agency <br />2610 University Ave W <br />St Paul, MN 55114 <br /> <br />we 00-04-22 <br />3836 639064 <br />