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policy ProJsions11WC000000C❑ <br />INFORMATION PAGE <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY <br />INSURER: SEE ATTAC❑ED E❑DORSEME❑T <br />NCCI Company Number: 20621 <br />Company Code: 9 <br />Suffix <br />LARS RENEWAL <br />POLICY NUMBER: 6 WEG B❑3❑P❑ <br />Previous Policy Number: 1:6 WEG A116AM❑ <br />1. Named Insured and Mailing Address: BEGI❑❑ERS EDGE SPORTS TRAI❑I❑G <br />o., Street, Town, State, ❑ip Code- ❑432 E TIERRA B❑E❑A L❑ <br />SCOTTSDALE All 8E260 <br />FEIN Number: 26-2932264 <br />State Identification Number(s): Refer to t❑e E❑TE❑SIO❑ OF TOE I❑FORMATIO❑ PAGE ❑ WC99036❑. <br />The Named Insured is: LLC <br />Business of Named Insured: Fitness and Recreational Sports Centers <br />Other workplaces not shown above: See Endorsement - WC990366 <br />2. Policy Period: From 11 /04/2 ❑ To 11 /04/26 A❑ ❑ ❑AL <br />12101 a.m., Standard time at tie insored® mailing address. <br />Producer's Name: I❑S❑RA❑CETRA❑ SER❑ICES/PAC <br />4❑1 ❑C❑L❑ER RD S❑ITE 206 <br />ROC❑ESTER ❑Y 14622 <br />Producer's Code: ❑62❑1042 <br />Issuing Office: T❑E ❑ARTFORD B❑SI❑ESS SER❑ICE CE❑TER <br />3600 WISEMA❑ BL❑D <br />SA❑ A❑TO❑IO T❑ ❑82111 <br />18❑❑❑28 E� 1316 <br />Total Estimated Annual Premium: 11q❑83 <br />Deposit Premium: <br />Policy Minimum Premium: 600 CA 7ncl❑des Increased Limit Min. Prem.- <br />Audit Period: A❑❑❑AL Installment Term: <br />Tie policy is not ❑ending -iless co-itersigned ❑y oEir aEtEori-ed representati-e. <br />Co-itersigned ❑y <br />AAEOri❑ed Representati::e <br />11 /04/2 ❑ <br />Date <br />Form WC 00 00 01 A (1) Printed in D.S.A. Page 1 :Contin❑ed on neEt page[] <br />Process Date: 11/04/2❑ Policy Expiration Date: 11/04/26 <br />