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<br />,.-UIlt..J rIUYIi;lIWIIIIiiI. .."" "'''' vV' -- I .. -- - --- --- <br /> <br />IttSURER: rid Hartlllld Accldenland I_IV Company 10448 <br />. Ll Hartford Cisually Inaur ompany 14397 <br />o Hartford Fire Insurance ..pany 13269 <br />o Hartford Underwriters Insurance Company 10456 <br />o T..Cily Fire Insurance Company 14974 <br />ADDRESS: P.o. Box 927, Dallas, 'Ix. 75221 <br /> <br />co. Code <br />S <br />Previous PoliW No. <br />7l iilZ fA9812 . '. <br /> <br />~ THE HARTFORD <br />IllIms . <br />1. Named lnand and Mailing Address <br />. (No., Street. Town, County, State) B rl <br />. ' Individual Corporation lL.I <br />'. .. . Partnership Other. on.... on....... <br /> <br />Otherwarkplal:llnotsbawnabave:2112 Genoa- Red Bluff, <br />Houston, 'rx. <br />2. The Policy Pin. illram 1-11-89 <br /> <br />I Producer'. Name <br />Day 11l8W:a.aC8 Service <br />~O 5&&881.- <br />tOG, tz. 77089 <br /> <br />to <br /> <br />1-11-90 <br /> <br />I <br />Producer's Codl I <br />113474 <br /> <br />'!~' . - ,. . ,'. . ~. . ' <br />....,."'1.'.'-;....'l.1 ~ ~-...-- - -...................'-,..-~ <br />,'~.:':. ; ~..J,:'>' <br />"'I' ~2'..,-~~'~"" '. ...;,~.rl,~;" ...... <br /> <br />I .t....."..:~~ ~ ~ . <br />. . ',>"2:" : .~-,,~,",":~. . <br />~~. <br />' _;r;J: <br /> <br />POUCY NO. 71 WZ lA9812 <br /> <br />M! <br />~J <br />I <br />I <br />I <br />I <br />I <br />,1 <br />01 <br />I <br />d <br />I <br />.\ <br /> <br />. <br /> <br />Hughes Sand Pi ta, lAc. & Pi t <br />Operationa, Inc. ' <br />P.O. . Box 4187 <br />Pasadena, T.z. 77502 <br /> <br />Houatol1, 'Ix. t 5201 E. Sam Houston, P~Jaray s. <br /> <br />12:01 A.M., standard time at the insured's mailing address <br /> <br />J <br /> <br />3., A. WIHUrl' Compeasa1Iaa Insurance: Part One of the policy applies to the Workers' Compensation Law of the states listed here: Tau <br /> <br />B. Employers' UabiJiIy Insurance: Part Two of the policy applies to work in each state listed in Item 3A. <br />The Umits of our!-i~ilily under Part Two are: Bodily Iniury by Accident $ 100 . 000 _ Each accident <br />Bodily IlIiury by Disease $ 500.000. Policy Umit <br />Bodily IlIiury by Diseases S 100 . 000. each employ" <br />C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: See EAdorseme11t <br /> <br />D. Thispolicyincludes1heseendorsementsandsched~les: we 42 03 01, we 77 00 00. we 00 02 02, we 00 03 la, <br /> <br />4. The premium for Ibis policy will be determined by our manuals ~~R:I~.OCia~t.bN.fns:ia~ JJRaUng PlIIIL <br />All information required below is subiect to verification and change by audit. <br /> <br /> . Pnlmium Basis Rate Per <br /> Code Esllmated Annual <br /> Claasilicationa Number Total Estimated $100 of PrImIum <br /> Annual Remuneralioa RIIIUIII8r3tIoa <br /> Clerical Office Employees Noc 8810 61.000. .5l 389. <br /> '"Mi- Woru 7590 189,962. 15.4~ 29,311. <br /> Ezecutive Officers Roc- Perfo~g Clerical <br /> or Outside Salespersons Duties Only 8809 130,000. .79 1,027. <br />. Experience HociificaUol1 Pending <br /> Expel1Se Col18tmt 0900 85. <br />& Ii .~.,o~ <br /> <br />Total Estimated Annual Premium S <br />Deposit Premium $ 30.812. <br />~ Monthly . S,1S3.. <br /> <br />I~bl/lntrastate ID No. 62815 <br />Mmlmum Pnndwn: $ . <br />Audit Period: c.J An~~ Semi-Annual 0 Quarterly <br />Form we 00 00 01 (Ed. OW4) Printed in U.SA <br /> <br />12-7. "-MJ_ <br /> <br />Countersigned by <br />aannr ',...ca'~ ,...naY <br /> <br />Au/JID#zrt/ AgIJI1t R-3 <br />