MARKEL INSURANCE COMPANY WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE

Transcription

1 MARKEL INSURANCE COMPANY WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Issued January 14, The Insured s Name and Mailing Address: CAMP LIVE OAK, INC NE 45th St Oakland Park, FL Standard NCCI Carrier Code: Renewal of Policy: MWC Fein # / Risk ID # For complete named insured: See Attached Named Insured Schedule Other work place not shown above: See Attached Location Schedule SIC CODE: 8351 Type of entity: Corporation 2. The policy period is from 01/23/2015 to 01/23/2016 [12:01 AM Standard Time] at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of this policy applies to the Workers Compensation Law of the states listed here: FLORIDA B. Employers Liability Insurance: Part Two of this policy applies to work in each state listed in Item 3A. The limits of our liability under Part Two are: Bodily Injury by accident: $ 100,000 each accident Bodily Injury by disease: $ 500,000 policy limit Bodily Injury by disease: $ 100,000 each employee C. Other States Insurance: Part Three of this policy applies to the states, if any, listed here: All states except those listed in Item 3A of the Information Page and the following states or territories: AZ, District of Columbia, ID, IL, ME, MA, MT, NJ, NY, ND, OH, OR, WA, WY, Puerto Rico and US Virgin Islands. D. This policy includes these endorsements and schedules: See Attached Schedule of Schedules and Endorsements 4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All Information required is subject to verification and change by audit. Code No. Classifications Minimum Premium: $ Producer: Allentown - Automatic Data Processing Ins Agency Inc Premium Basis Total Rate per $100 of See Attached Schedule of Classification and Premium Detail Premium Premium for Increased Limits Part Two $0.00 Total Premium Subject to Experience Modification $3, Total Estimated Standard Premium $3, Premium Discount, if applicable $0.00 Expense Constant Charge $ Terrorism Insurance $39.00 Total Premium $3, Countersigned By: Servicing Office: Date: 01/14/2015 THIS INFORMATION PAGE WITH THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY AND ENDORSEMENTS, IF ANY ISSUED TO FORM A PART THEREOF, COMPLETES THE ABOVE NUMBERED POLICY WC A *DOCID * of 29 *MWC * MWC

2 EXTENSION OF INFORMATION PAGE - ITEM 4. SCHEDULE OF CLASSIFICATION AND PREMIUM DETAIL Code Classification Premium Basis Total Rate Per $100 of Estimated Annual Premium Child Day Camp - All Employees Including Clerical, salespersons & Drivers Child Day Camp - All Employees Including Clerical, salespersons & Drivers $193, $3, $ $ Clerical Office Employees Noc $ $0.00 Manual Premium $3, Subject Premium $3, Total Subject Premium $3, Modified Premium $3, Standard Premium $3, Expense Constant $ Terrorism $39.00 Premium $3, WC000001A 2 of 29

3 EXTENSION OF INFORMATION PAGE - ITEM 3.D. SCHEDULE OF SCHEDULES AND ENDORSEMENTS Form # Edition Description MWC 1201 Ed Policy Payment Schedule WC000000C Ed WC and Employers Liaiblity Insurance Policy WC Ed Partners, Officers and Others Exclusion Endorsement WC Ed Pending Rate Change Endorsement WC000406A Ed Premium Discount Endorsement WC Ed Notification of Change in Ownership Endorsement WC Ed Premium Due Date Endorsement WC Ed Florida Employers Liability Coverage Endorsement WC Ed Florida Experience Rating Modification Factor Endorsement WC090403A Ed Florida Terrorism Risk Insurance Extension Act Endorsement WC Ed Florida Non-Cooperation With Premium Audit Endorsement WC Ed Florida Employment and Wage Information Release Endorsement WC Ed Signature Page MPIL 1007 Privacy Notice MPWC 1001 Ed FL Safety Consultation Notification MPWC 1002 Ed FL Premium Discount Awareness Notification WC Ed Florida Dividend Plan Endorsement Form 09-Notice Ed Florida Notice of Pending Law Change to Terrorism Risk Insurance Program Reauthorization Act of 2007 WC000001A 3 of 29

4 EXTENSION OF INFORMATION PAGE - ITEM 1. LOCATION SCHEDULE Location FEIN PHONE E Sunrise Blvd Fort Lauderdale FL, NE 163rd St Miami FL, NE 45th St Oakland Park FL, SIC CODE ENTITY TYPE WC000001A 4 of 29

5 EXTENSION OF INFORMATION PAGE - ITEM 1. NAMED INSURED SCHEDULE CAMP LIVE OAK, INC. WC000001A 5 of 29