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POLICY NUMBER: :ro WEG B❑3i❑P❑ <br />NAME OF INSURER: ❑artford Insi-irance Company of Illinois <br />Oil President and Secretary iEaEo signed t:Js policy <br />co htersigned Ey o:l-d:1y a::t::Ori::Od representatiE0. <br />❑e:ln Barnett, Secretary <br />W'❑ere re❑gyred ❑y law, t'—e Information Page iDas iDeen <br />A. Morris TooiFor, President <br />InclEdes copyrigiA material ofti-le ❑ational CoEncil on Compensation Ins!iance, Inc. !wed wit❑its permission. <br />❑ 2000 ❑ational Co!Encil on Compensation Instance, Inc. All Rig!Ets ReseriEod. <br />DELAWARE ❑ <br />Delaware forms i-18::0 iDeen copyrigEted ❑y tEe Delaware Compensation Rating Berea❑Inc. <br />❑EW YOR'❑'❑ <br />Inch -des copyrig❑ted material of tEie ❑ew Yor❑Compensation Insiiance Rating Board, 'wed wit❑ its permission. <br />❑ 2021 ❑ewYor❑Compensation Insiiance Rating Board, all rig As reseriEOd. <br />❑ORT❑ CAROLI ❑A❑ <br />Inch -des copyrigiAed material of tEie ❑ort❑Carolina Rate Berea❑, 'wed wit❑its permission. <br />PE❑❑SYL❑A❑IA'❑ <br />PennsylE:inia forms Fia::o iDeen copyrigEted ❑y tEe Pennsyli-:8nia Compensation Rating BF1reaE1 <br />Form WC 99 00 01 K Printed in ❑.S.A. <br />Page 1 of 1 <br />Process Date: 11/04/2❑ <br />Policy Expiration Date: 11/04/26 <br />