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WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br /> • `� EXTENSION SCHEDULE FORM NUMBER: WC co 00 U1 <br /> ® FREMONT INDEMNITY COMPANY COMSTOCK INSURANCE COMPANY <br /> NEW SCHLDULE : A <br /> POLICY NUM3rK: CW66-394760-U1 PAGE: 1 <br /> POLICY P'-R1JD: 05/L1/86 TO 45/01/87 EFFECTIVE DATE: 05/C1/86 <br /> INSURED: ASSEMBLY OF GOD ISSUED DATE: 06-13-66 <br /> THE IIirURMATION PAGE IS EXTENDED AS FOLLOWS: <br /> ITEM 4. ADDITIONAL CLASSIFICATIONS: <br /> PREMIUM <br /> ST . CODE CLASSIFICATION BASIS RAIE EAP <br /> CA 8840 CHURCHES—CLERGY, PROFESSIONAL — 409176 1 .13 — 454 <br /> ASSISTANTS, ORGANISTS, OR MEM6ERS <br /> OF CHOIR—INCLUDING CLERICAL OFFICE <br /> EMPLOYEES- <br /> WHLN LODGING IS PROVIDED BY THE <br /> EMPLUYER, THE TOTAL REMUNERATION <br /> E SHALL INCLUDE THE MARKET VALUE OF <br /> 3 SUCH LODGING TO THE EMPLOYEE . <br /> CA 9G15D CHURCHES—ALL EMPLOYEES OTHER THAN 11, 697 9.60 1, 123 <br /> CLERGY I PROFESSIONAL ASSISTANTS, <br /> d ORGANISTS, MEMBERS OF CHOIR OR <br /> CLEKICAL OFFICE EMPLOYEES. <br /> WHEN LODGING IS PROVIDED BY THE <br /> o EMPLOYER THE TOTAL REMUNERATION <br /> SHALL IN�LUDL THE MARKET VALUE OF <br /> SUCH LODGING TO THE EMPLOYEE . <br /> 0 <br /> E <br /> E <br /> 0 <br /> x <br /> 9 PRUOUCER : AVERY-HAMMER INSURANCE ASSOCIATES, INC <br /> V <br /> CODE: : 3&27/1t Cl EDWARD J. LIEBE R,SECRETARY <br /> INSURED <br />