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<br />: tirac <br /> <br />: BerIdey Risk Admiishkn Onpany. UC <br /> <br />Minnesota Workers' Compensation. Ass~gned Risk Plan <br />Standard Workers' Compensation and.Employers' Liability.p,Olicy <br />Contract .Administrator <br />Berkley ~isk Administrators Com'pany, LLC <br />P.O. Box 59143 Minneapolis, Minnesota 55459-0143 <br />Phone (612) 766.3000 Neel' Carrier Code 21466 <br />INFORMATION PAGE <br /> <br />Renewal Of No. WC-22-o4-159728-00 <br /> <br />- 1. The In~ured: <br />GNAW INC <br />dba: Centerville Liquors <br />7093 20th Ave <br />Centervllle, MN 55038 <br /> <br />, WCIP. <br /> <br />Policy Number: WC-22-o4-159728-o1 <br />Association File Number: 3201395 <br /> <br />Other workplaces not shown above: <br /> <br />TaxIDf:F830385468 <br />Ule #: 068707550000 <br />Date of Mallin'g: 11flM005 <br />D Indivi~ual D Partnership <br />00 Corporation D Other <br /> <br />~.. <br />'E '. {. '" ~ "{.. <br />2: The policy period is from 12:01 a.m.1/612006 to 12:01 a.m~ 1/612007 at the insured's mailing address. <br />: 3.A. Workers' Compensation Insurance: Part One of the policy applies to the Workers' Compensation LaW of the states listed here: <br />, MN <br />B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. <br />The limits of our liability under Part Two are: Bodily Injury By Accident $100,000 each accident. <br />Bodily Injury By Disease $500,000 policy limit. <br />8o.dlly Injury By Disease ~1 00,000 each employee. <br />C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: <br /> <br />D.'This policy includes these endorsements and schedules: <br />WC000403 WCOOO414 WCOOO419 WCOOO422 WC220000 WC220301 WC220402 WC220601C WC220620 WC990001A WC990809 <br /> <br />4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. <br />All information required below is subject to verification and change by audit. ' <br /> <br /> PREMIUM BASIS RATES ENTRIES IN THIS ITEM, EXCEPT AS SPECIFICALLY PROVIDED ESTIMATED <br /> ESTIMATED TOTAL PER $100 OF CODe ELSEWHERE IN THIS CONTRACT; DO NOT MODIFY ANY OF ANNUAL <br /> ANNUAL REMUNERATION NO. THE OTHER PROVISIONS OF THIS POLICY. PREMIUM <br /> R1=UI'" ,-- '-.~tt.1 <br /> ~. Manual Premium $75~OO <br /> fr <br /> See Schedultf' Standard Premium ' $75.00 <br /> Adjusted Standard Premium $75.00 <br /> Minimum Premium: $220.00 Expense Constant $160.00 <br /> For~lgn T~rrorlsm Stat Code 9740 $1.00 <br /> Estimated Annual Premium $236,,00 <br /> Special Comp. Fund Surcharge Stat Code 0174 1.041 $3.00 <br /> POlley Total Estimated Cost $239.00 <br />t Net Deposit Premium Required $239.00 <br /> Aaenev Name ~nd Address- Premium Paid to Date ($239.00) <br /> Total Premium Due $0.00 <br /> Ross Nesbit Agencies Inc <br /> Paulet Slater Agency <br />, 261 Q. University Ave W - ~ ~ <br /> " <br /> St Paul, MN 55114 <br /> <br />i ... . <br />I <br />, <br />I <br /> <br />pATE: 11/28/2005 <br />f <br />1. <br /> <br />~~y. <br /> <br /> <br />Includes copyright material of the NatlonafCouncil on Compensation Insurance used with its permission. <br />@ 1983 _ @ 1991 National Council Compensation Insurance <br /> <br />Signature: <br /> <br />WC 99-00-01 <br />1532 468565 <br /> <br />~ <br /> <br />i . <br />