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CHUBS' <br /> ISS U ING COMPANY Workers'Compensation <br /> ACE AMERICAN INSURANCE COMPANY <br /> NMI CARRIER CODE and Employers Liability <br /> 12165 Insurance Policy <br /> Information Page <br /> POLICY NUMBER ❑New ©Renewal ❑Rewrite <br /> Symbol:WLR Number:C6 60 38 62 2 <br /> PREVIOUS POLICY NO. ❑Individual— F]Partnership F1Association <br /> Symbol:WLR Number:C65224987 ❑X Corporation ❑Joint Venture ❑Other Legal Entity <br /> Item 1. FEGION CORPORATION Inter/Intrastate ID No.:917261423 <br /> Named 17988 EDISON AVE <br /> Insured CHESTERFIELD MO 63005 Federal Employer ID No.:453117900 <br /> Mailing <br /> Address <br /> Employees ID No.: <br /> arseva�r+x+7ax+ew - PITC CODE:1389 <br /> For other named insured see Extension of Information Page-Schedule of Named Insured,WC 99 99 99 A <br /> For other workplaces see Extension of Information Page-Schedule of Other Workplaces,WC 99 9999 B <br /> --, - - Item 2. Policy period: From 07-01-2019 To 07-01-2020 12:01 AM.,standard time at the named insured's mailing address. <br /> Item 3A. Workers'Compensation Insurance:Part One of the policy applies to the Workers'Compensation Law of the states listed here: <br /> AZ,CA,MA <br /> 371SB43A*N 1211=10W <br /> s <br /> Item 3B. Employers Liability Insurance:Part Two of the policy applies to work in each state listed in Item 3A. <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 /> Item 3C. Other States Insurance: Part Three of the policy applies to the states,if any,listed here: <br /> Q Incatat»rlrupl.,sa4tlwmta4sx O ALL STATES EXCEPT <br /> ma.cwwramBcrmi ND,OH,WA,WY, <br /> R AND STATES DESIGNATED IN ITEM 3.A <br /> OilAara,ItM.YW, unr.o,a+.we...w <br /> �rlyd s«u,�.uvvue 0 � Item 3D. This Policy Includes these endorsements and schedules: <br /> p <br /> See schedule of Fortes and Endorsements WC999999D <br /> Item 4. The premium for this policy will be determined by our Manual of Rules,Classifications,Rates and Rating Plans.All information <br /> required below is subject to verification and change by audit. <br /> SEE EXTENSION OF INFORMATION PAGE-CLASSIFICATIONS <br /> If indicated here,interim adustmenls of premium will be made: Minimum Premium collected in AZ $ <br /> ElSemi-Annually []Quarterly ❑Monthly Total Estimated Premium <br /> Deposit Premium $ <br /> PRODUCER NAME AND MAILING ADDRESS <br /> LOCKTON COMPANIES LLC <br /> 3 CITY PLACE DRIVE <br /> SUITE 900 <br /> SAINT LOUIS MO 63141 <br /> PRODUCER CODE: 271194 20-3354970 CGU <br /> MARKETING OFFICE: CHICAGO BRANCH <br /> ISSUE DATE: 06/26/2019 <br /> Authorized Representative <br /> d WC 00 00 01A(05/88) Copyright 1987 National Council on Compensation Insurance <br /> INSURED COPY <br /> r <br />