Laserfiche WebLink
WCOOOOOIB <br />TOWER SELECT INSURANCE COMPANY <br />120 BROADWAY <br />NEW YORK, NY 10271 A-2008-072 <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />INFORMATION PAGE <br />NCCI No: 33480 Policy No : TSIWD7 0813776 00 <br />New No.: TSIWD7 0813776 00 S1C Code: 7338 Renewal of Policy No.: NEW <br />State Unemployment I.D. No. or Identifying Number as Required: <br />1. Insured: US ADVOCACY <br />Mailing PO BOX 698 <br />Address: ORANGEVALE, CA 95662 <br />Ownership Type: Corporation <br />Other workplace not shown above: <br />FEIN :20-1279851 <br />Producer: ILLINOIS MIDWEST INSURANCE AGENCY, LLC. <br />Mailing P.O. BOX 9560 <br />Address: SPRINGFIELD, IL 62791-9560 <br />DBA Name: <br />2. The policy period is from 06/01/2008 To 06/01/2009 12:0] A.M Standard Time, at the inswed's mailing address <br />3. A. Workers Compensation insurance: Part One of the policy applies to the Workers Compensation Law of the states <br />Listed here :California <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 the liability under Part Two areBodily Injury by Accident $ 1,000,000 each accident <br />Bodily Injury by Disease $ 1,000,000 each employee <br />Bodily Injury by Disease $ 1,000,000 policy limit <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 ,West Virginia ,Wyoming <br />D. This policy includes these endorsements and schedules: <br />WC 0 0 00 00 A WC 0 0 00 Ol B WC 0 0 O1 13 WC 0 0 04 22 WC 0 4 03 Ol A WC 0 4 03 10 <br />WC 0 4 03 60 A WC 0 4 04 07 WC 0 4 06 O1 A <br />4. The premium for this policy will be determined by our Manuals of Rules ,Classification ,Rates and Rating Plans. <br />All information required below is subject to verification and change by audit. <br />Classifications Code No. Premtum Basts Rate Per Estimated <br />Total Estimated $100 of Annual <br />Annual Remuneration Remuneration Premium <br /> Please see Attached Schedule <br /> Total Manual Premium 328 <br /> Total Standard Premium 328 <br />0900 Expense Constant 160 <br />9740 Foreign Terrorism Premium 16 <br /> Estimated Annual Premium 504 <br />9695 California Guarantee Fund Assessment 10 <br />9681 California Fraud Surcharge Assessment 1 <br />9682 California Workers' Compensation Admin Fund Assessment 5 <br />9700 California Uninsured Employer's Benefits Fund Assessment 1 <br /> Total Amount Due 521 <br /> Policy Minimum Premium 251 <br />d~~~ <br />If indicated below ,interim Adjustements of Premium shall be made <br />O Annually O Semi Annually O Quarterly O Monthly Deposit Premium <br />Issuing Office: 120 Broadway Page 1 Of 5 <br />New York, NY 10271 <br />Countersigned by: <br />Issue Date:04/22/2008 <br />