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StateFarm <br />• WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY <br />SURCHARGE OVERFLOW PAGE <br />PAGE NO: 01 23-2463 FAC1 <br />POLICY NO. 92-GO-D366-6 COVERAGE IS PROVIDED BY <br />POABoxF853925, RiRE chhardsonLTX COMPANY55-925 <br />PREPARED 05/07/2021 <br />LBR ENAFMT COMPLSASMT $ 11.00 <br />SUUBCINJFBENEFITS ASMDT $ 4.00 <br />WC990003(ED 3-11) <br />�ortaN <br />3 z <br />RAMmWmentDMsian <br />REVIEWED & APPROVED BY: <br />Risk Management Analyst <br />