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a~/le/2000 08:38 5e35288804 B~RKER SUR~EYING CO PAGE 02 <br />, W~JRKERS CO1v~PENSATION AND EMPLOYERS LIABILITX INSURANCE POLICY <br />INFORMATION PAGE po~lcy No. <br />NCCI Co. No WC1-1204120 <br />36935 v1N~nov~ lirunno~ oomp~nr <br />1. LNSURED: Renewat of Pollcy No. <br />The Insured/Mailing eddrese NCW <br />Barker Surveying Co. , <br />2035 25th St. SE ^ Individuel ^ Parfiership ' <br />Salem, OR 97302 X[~ C <br />orporation or <br />Insured's I.D. No.(s). (if applieable) <br />Other workplaces not show~ abovo: F_E.[.N. ~ 93-1058015 <br />Risk ID # 360909964 <br />2. POLICY PERIOD: Thopoticyperiod is from 04/01/2000 to OQ/01/2001 12:0] A.M. Standard Time, <br />et the Insured's mailing address. <br />3. COVERAGE: <br />A. Workers Compensation Insurance: Part One of the policy spplies to the Workera Compensation Law of the states <br />listed here: Oregon <br />B. Employers Liability Insurence: Part T~vo of the policy appliea to work in each state list~d in item 3.A. The limics of our <br />liability under Part'I1vo are: Bodily Injury by Accident S 100,000 each accldent <br />Bodily Injury by Disease S 500,000 policy limit <br />Bodily Injury by Disoase S 1Q0,000 each employee <br />C. Other Stetes Inaurance: Part Throe of the policy appliee to the atsbes, if arty, lieted hero: <br />D. This policy inetudes these endoraemente end schedules: <br />See GU207A <br />4. PREMIUM: Tho promium for this policy will bo dotormined by our Msnuala of Rules. Classifications, Rates end Reting <br />Plans. All information re uirod below fa eub ect to verltication and chan c by nudit. <br /> Code Promlum B~sls Rntes Pe~ ~stimatod Annual <br />Cla~sificetions No. Totel Estlmeted S 100 of Premium <br /> Annual Remunerntlon Re:~~.~~era!fon <br />s~c coae : 8712 <br />See R'C 99 03 09 <br />If indicated below, interim adjustments of premium Premium for Increesed Llmits Part Two <br />if nppliceble S <br />, <br />shaU be made-- Tote! Premlum SubJeet ~o the Experience Modification s <br />~ Semiannuelly: ~ Querterly; ~ Monthly Premium Modifled to Reflect Experionce Mod. of f <br />Oregon wC Asaeasment 155 s <br />Tota! Fatimeted Stsndard Premlum s <br />Ptemium Di~count, if ~ppllceble s <br />EYpenae Constant Charge f <br />uat Prcmium s <br />Minimum Premium S 113 De oeit Premlum S 531.25 Totel Estimated Annuel Premium f 2,125 <br />Neme of Producer: Groet Northem Underwrits~x <br />SCNICipg Offlte: 1800 SW Fourth Avenue Countetaigned By <br />Sulte 900 Au~horirsd Rtptrunuti.~e DNe <br />128401 Pa~and, OR 87201 03/23/'Zi D0~ <br />THIS INfORMATION PAOfi WITH THE WORKERS COMP6NSATION ANO 6MPLOYERS LtABlLITY INSURANCE POLICY AND <br />910009 (Fd. I-98) ENDORSEMENTS. IF ANY, lSSUEO TO f00.M A PAATTHEREOP, COMPI,BTFS THE ABOVE NUM8ERE0 POLICY, wC 00 OOOI ~ <br />COPYR[OHT 1917, NATIONAL COUNCIL ON COMPHNSATI~N INSURANCF. <br />