Fill and Sign the Workers Comp Insurance Policy Info Allied Community Form

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 01 A Original Printing Issued May 1, 1988 Standard INFORMATION PAGE POLICY NO. Insurer: 1. The Insured: _____ Individual_____ Partnership Mailing a ddress: _____ Corporation or___________________ Other workplaces not shown above: 2. The policy period is from ______________________ to ___________________ at the insured’s mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ ___________________________ each accident Bodily Injury by Disease $ ___________________________ policy limit Bodily Injury by Disease $ ___________________________ each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: D. This policy includes these endorsements and schedules: 4.. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information req uired below is subject to verification and change by audit. Classifications Code No. Premium Basis Total Estimated Annual Remuneration Rate Per $100 of Remuneration Estimated Annual Premium Total Estimated Annual Premium $ Minimum Premium $ Expense Constant $ Countersigned by _____________________________________________ I D-49 ãã 1987 National Council on Compensation Insurance. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 01 A Original Printing Issued June 1, 1991 Standard GENERAL INFORMATION PAGE NOTES 1. Insurance carriers may show a renewal agreement statement on the standard Information Page when a policy is renewed. The carrier must show “Renewal Agreement” or a like heading along with the title “Infor mation Page” if a renewal agreement statement is shown on the Information Page. 2. Insurance carriers showing a renewal agreement statement on the Information Page or entering into a renewal agreement not shown on the Information Page may list any or a ll endorsements in Item 3.D., elsewhere on the Information Page or in an Information Page Schedule. A carrier is not required to attach such listed endorsements to the Information Page and Policy if the endorsements have already been provided to the insure d by that carrier. 3. These General Information Page Notes do not affect the standard Information Page entry requirements set forth in the Information Page Notes. D-49 ãã 1988, 1991 National Council on Compensation Insurance.