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INFORMATION PAGE (Continued) <br />Policy Number:76 WEG AZ6AMU <br />3.A. Workers Compensation Insurance:Part one of the policy applies to the Workers Compensation Law of the states <br />listed here:CASEE 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$1,000,000each accident <br />Bodily injury by Disease$1,000,000policy limit <br />Bodily injury by Disease$1,000,000each 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 />ClassificationsTotal EstimatedRates PerEstimated <br />Code Number andAnnual$100 ofAnnual <br />DescriptionRemunerationRemunerationPremium <br />Total Standard Premium$1,817 <br />Expense Constant$200 <br />Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement$26 <br />Catastrophe (Other Than Certified Acts Of Terrorism)$16 <br />Estimated Annual Premium (before Surcharges)$2,059 <br />Total Estimated Surcharges$74 <br />*See the attached Schedule(s) of Operations for Location and State Level Premium Information <br />Total Estimated Annual Premium:$2,133 <br />Deposit Premium: <br />Policy Minimum Premium: <br />$600CA (Includes Increased Limit Min. Prem.) <br />Interstate/Intrastate Identification Number:Refer to Schedule of Operations <br />NAICS: 713940 <br />Labor Contractors Policy Number:SIC:7991 <br />Form WC 00 00 01 A(1)Printed in U.S.A.Page 2 <br />Process Date:08/17/24Policy Expiration Date:09/26/25 <br /> <br />