Laserfiche WebLink
<br />r <br />~. <br /> <br />)/Minnesota Workers' Compensation Assigned Risk Plan <br />, Standard Workers' Compensation and Employers' Liability Policy <br /> <br />') Contract Administrator <br />)""'_' lie Berkley Risk Administrators Company, LLC <br />xl( P,O. Box 59143 Minneapolis, Minnesota 55459-0143 <br />,/1 Phone (612) 766-3000 NCCI Carrier Code 21466 <br /> <br />f /1'. INFORMATION PAGE <br /> <br />k1;~:\~:::d:New WCIP <br /> <br />./ Center Mart LLC <br />" 1801 Main st <br />Centerville, MN 55038 <br /> <br />Policy Number: WC-22-04-155855-00 <br />Association File Number: 3186600 <br /> <br />Other workplaces not shawn above: <br /> <br />Tax ID#: F 201141552 <br />UIC #: UNKNOWN <br />Date of Mailing: 711212004 <br />o Individual 0 Partnership <br />o Corporation [K] Other <br />Limited Liability Company (LLC) <br /> <br />2. The poiicy period is from 12:01 a.m, 71212004 to 12:01 a,m. 71212005 at the insured's mailing address. <br />3.A. Workers' Compensation (nsurance: Part One of the policy applies to the Workers' Compensation Law of the states listed here: <br />MN <br /> <br />B. Employers liability Insurance: Part Two of the policy applies to work in each state Iiste~ 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 />Bodily Injury By Disease $100,000 each employee. <br />C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: <br /> <br />~ <br /> <br />D. This policy includes these endorsements and schedules: <br />WC000308 WC000403 WC000414 WC000419 WC000420 WC220000 WC220601A WC990001A WC990601 WC990S0S <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 />I <br />I <br />I <br />, <br />, <br />, <br />.1 <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 />RF'M~~~~ALICl~ REMUNERATION NO, THE OTHER PROVISIONS OF THIS POLiCY, PREMIUM <br />N RATI N <br /> Manual Premium $586.00 <br />See Schedule Standard Premium $586.00 <br /> Adjusted Standard Premium $586.00 <br />Minimum Premium: $223.00 Expense Constant $150.00 <br /> Terrorism Coverage Stat Code 9740 $4.00 <br /> Estimated Annual Premium $740.00 <br /> Special Compo Fund Surcharge Stat Code 0174 1.045 $26.00 <br /> Policy Total Estimated Cost $766.00 <br />AQency Name and Address Net Deposit Premium Required $766.00 <br />All County Agency Premium Paid to Date ($773.00) <br />255 SE Hwy 97 Suite 38 Refund Due $7.00 <br />Forest Lake, MN 55025 <br /> <br />DATE: 7/12/2004 <br /> <br />-;-~~v. <br /> <br />Includes copyright material of the National Council on Compensation Insurance used with Its permission. <br />@1983J@ 1991 National Council Compensation Insurance <br /> <br />Signature: <br /> <br />we 99-00-01 <br />1206 365851 <br />