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C H U S S11 <br /> ISSUING COMPANY Workers' Compensation <br /> ACE AMERICAN INSURANCE COMPANY <br /> NCCI CARRIER CODE and Employers Liability <br /> 12165 Insurance Policy <br /> Information Page <br /> POLICY NUMBER ❑ New ❑X Renewal ❑ Rewrite <br /> Symbol: WLR Number:C6 60 38 62 2 <br /> PREVIOUS POLICY NO. ❑ Individual ❑ Partnership ❑ Association <br /> Symbol: WLR Number: C65224987 ❑X Corporation ❑ Joint Venture ❑ Other Legal Entity <br /> Item 1. FAEGION 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 /> Employer's ID No.: <br /> PIIC 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 99 99 B <br /> Item 2. Policy period: From 07-01-2019 To 07-01-2020 12:01 A.M., 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 /> Item 313. 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 /> ALL STATES EXCEPT <br /> ND,OH,WA,WY, <br /> AND STATES DESIGNATED IN ITEM 3.A <br /> Item 3D. This Policy includes these endorsements and schedules: <br /> See schedule of Forms 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 ad'ustments of premium will be made: Minimum Premium collected in AZ $ <br /> ❑ Semi-Annually LJ 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 /> WC 00 00 0 1 A(05/88) Copyright 1987 National Council on Compensation Insurance <br /> INSURED COPY <br />