Laserfiche WebLink
South Carolina Workers' Compensation Insurance Plan <br />Riverport Insurance Company <br />r y Administered by Berkley Risk Administrators Company, I-I_C <br />�rt = rS P.O. Box 59143 Minneapolis, Minnesota 55459-0143 <br />��..< Phone (612) 766-3000 Fax (866) 215-8118 Toll Free (888) 548-7431 <br />NCCI Carrier Code 27995 <br />INFORMATION PAGE <br />Renewal Of No. WC-39-84-008T44-02 <br />1. The Insured: WCiP <br />GOVERNMENT TRAINING INSTITUTE INC <br />3858 N Garden Center Way Ste 300 <br />Boise, ID 83703 <br />Other workplaces not shown above: <br />See Schedule <br />Policy Number. WC-3944-008744-03 <br />Risk ID: 910d47505 <br />Tax ID#: F 20-0052493 <br />Date of Mailing: 712512011 <br />Individual �] Partnership <br />C irporstlon [] Other <br />2. The policy period Is from 12:01 am. BIW2011 to 12:01 a.m. BIW2012 at the insureds mailing address. <br />3.A. Workers' Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the states listed here: <br />se <br />B. Employers Liability Insurance: Part Two of the policy apples to work in each state listed in item 3.A. <br />The limits of our liability under Part Two are: 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 />SEE WC 00-03-26 (A) <br />D. This policy includes these endorsements and schedules: <br />WC000308 WC000326A WC000402 W0000403 WC000404 WC000414 WC000415B WC000417B WCOOD419 WC000421C WC000422A <br />WC990001A WC9W601 <br />4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. <br />All information required below is subject to verification and change by audit. <br />PREMIUM BASIS RATES ENTRIES IN THIS ITEM, EXCEPT AS SPECIFICALLY PROVIDED ESTIMATED <br />ESTIMATED TOTAL PER $100 OF I <br />CODE ELSEWHERE IN THIS CONTRACT; DO NOT MODIFY ANY OF ANNUAL <br />ANNUAL REMUNERATION NO. THE OTHER PROVISIONS OF THIS POLICY. PREMIUM <br />See schedule I <br />Minimum Premium: 1 $900.00 <br />Agency Name and Address <br />Willis of Tennessee Inc <br />PO Box 2827 <br />Columbia, SC 29202 <br />wal Premium <br />$6,015.00 <br />eased Limits <br />Stat Code 9812 <br />$187.00 <br />Ject Premium <br />$8,g62,to <br />srienae Modification <br />0.93 <br />($480.00) <br />filled Premium <br />$61"100 <br />d° <br />1.00 <br />$0.00 <br />xdard Premium <br />$6,382.00 <br />ense Constant <br />$230,00 <br />brism <br />Stat Code 9740 <br />$4&00 <br />istrophe <br />$tat Code 9741 <br />$24.00 <br />it Estimated Annual Premium <br />$6,884.00 <br />if Fees 3 Premium <br />$6,684.00 <br />Deposit Premium Required <br />$5,013.00 <br />nium Paid to Date <br />($0,684.00) <br />if Premdunn Due <br />APPROVED AS TO FORA1 <br />$0.00 <br />�71ER <br />Auis nt City Attorney <br />DATE: 7t2512011 <br />Signature:/ <br />6119953.@ Ami 90 hNa and co-ra Natlorid" *#w i an cornonco sap m Insu ence used ils pem�swn. � <br />c.�+r»ruesm, Mrsixrr,ce .. C 93-00-01 <br />