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troucy rrovrsions: riu uu vu v <br />. INSURER: Gd HartfordNccidenta <br />Hertford Casualty U <br />^ Hartford Fire Insure <br />^ Hartford Underwrite <br />^ TwinGty Fue Incur <br />AOORESS: P.O. sox 927, <br />Icy THE HARTFORD <br />1. Named Insured and Mailing Address <br />(No., SVeet, Town, County, State) <br />individual 8 Corporation <br />.. Partnership Other .................. <br />vYcaa~~.vaa~, ...a,. <br />P.O. Box 4187 <br />Pasadena, Tz. 77502 <br />Other workplaces not shown above: 2122 Genoa- Red 81uf f , Houston. Tx . ; 5201 E . Sam Houston, Parlcxay S. <br />Houston, Tx. <br />2. Trio Policy Period is from ~ -13-~9 to L-~ ~-QO 12:01 A.M., standard time at the insured's mailing address <br />Producer's Name Producer's Code <br />Day Insurance Service 213474 <br />0030 Sage>eglar <br />ton, Tx. 77089 <br />3. A. Worker:' Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the states listed here: Texas <br />B. Employers' Uability Insurance: Part Two of the policy applies to work in each state listed in Item 3A. <br />The Umits of ou! liability under Part Two are: Bodily Injury by Accident S ~,~ nnn Each accident <br />Bodily Injury by Disease S Snn nnn Policy Omit <br />Bodily Injury by Diseases S n ^ each employee <br />C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: See Endorsement <br />D. This poUcy includes these endorsements and schedules: WC 42 03 01, wC 77 00 00, WC 00 02 02, wC 00 03 ~0, <br />4. The premium for this policy will be determined by our manuals o Rules, asst t~abons, tes a atittq Plans. <br />All information required below is sulyect to verification and change by audit. <br />Premium Basis Rate Per <br />Classificatlons Code Total Estimated 5100 of ~~~ Annual <br />Number Annual Remttttention Rettttuteratfat Premium <br />Clerical Office Employees Noc ~ 8810 <br />Garbage iiorlca ~ 7590 <br />Executive Officers isoc- Performing Clerical <br />or Outside Salespersons Duties Only 8809 <br />Experience Modification Pending <br />Expense Constant <br />~~~ <br />IMerstate~lntrastate ID No. 62815. <br />Minimum Premium: t <br />Audit Period: Ann See <br />Foam WC 00 00 01 (E0.04-84) Pfinted in U.SA <br />0900 <br />67,000. .5 389. <br />189,962. 15.4 29,311. <br />130,000. .7 1,027. <br />Total Estimated Annual Premium = 30, 812 . <br />DeposB Premitnn S <br />Yq C M C P I' <br />~~ <br />x <br />85. <br />,~~~.. <br />Countersigned by <br />PR~~IlCER'S COPY <br />Audraiired Agent R-3 <br />