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INFORMATION PAGE (Continued) <br />Policy Number: 59 WEC AC9055 <br />3. A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the states <br />listed here: WI SEE ENDORSEMENT - WC 99 03 67 <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: <br />Bodily injury by Accident $1,000,000 each accident <br />Bodily injury by Disease $1,000,000 policy limit <br />Bodily injury by Disease $1,000,000 each employee <br />C. Other States Insurance: Part Three of the policy applies to the states, if any , listed here: <br />ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WYOMING, U.S.TERRITORIES AND STATES <br />DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE. <br />D. This policy includes these endorsements and schedule: <br />SEE ENDORSEMENT -WC 99 03 68 <br />4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating <br />Plans. All information required below is subject to verification and change by audit. <br />Premium Basis <br />Classifications Total Estimated Rates Per Estimated <br />Code Number and Annual $100 of Annual <br />Description Remuneration Remuneration Premium <br />Total Standard Premium <br />Premium Discount <br />Extended Broad Form Coverage <br />Expense Constant <br />Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement <br />Catastrophe (Other Than Certified Acts Of Terrorism) <br />Estimated Annual Premium (before Surcharges) <br />Total Estimated Surcharges <br />*See the attached Schedule(s) of Operations for Location and State Level Premium Information <br />Total Estimated Annual Premium: $71,141 <br />Deposit Premium: <br />Policy Minimum Premium: $1,150 NC (Includes Increased Limit Min. Prem.) <br />Interstate/Intrastate Identification Number: Refer to Schedule of Operations <br />NAICS: 722110 <br />Labor Contractors Policy Number: SIC: 5812 <br />Form WC 00 00 01 A (1) Printed in U.S.A. <br />Process Date: 05/25/20 <br />$70,102 <br />-$2,394 <br />$1,179 <br />$250 <br />$308 <br />$156 <br />$69,601 <br />$1,540 <br />ew cF RAMwagementDMsian <br />Jy/ \'x REVIEWED & APPROVED BY. - <br />Page 2 ,,; V <br />Policy EXpirati —��— Wsk Pjanagement Analpt <br />