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WC000001 A
<br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
<br />INFORMATION PAGE
<br />Original Printing Issued February 12, 2018 Standard
<br />NCCI Carrier Code:35513
<br />Type : Stock Policy Number:
<br />FirstComp Insurance Company—n185667-01
<br />222 South 15th St. Ste 1500N
<br />ORenewal of Policy:
<br />maha,NE 681021680
<br />888-500-3344
<br />Rewrite of Policy: �^
<br />Fein # I Risk ID #:
<br />472909945/
<br />1. The Insured's Name and Mailing address: DBA Name:
<br />INVO Cleaning Services LLC SIC CODB:7349
<br />PO Box 1261
<br />South Bend, IN 46624-1261
<br />Phone:5742502400
<br />Other work place not shown above:See Attached Location Schedule Type of entity: ILimited _Liability Company
<br />2• The policy period is from02/23/2018 to 02/23/2019 112.01 AM Standard Time] at the insured's mailing address.
<br />3. A. Workers Compensation Insurance: Part One of this policy applies to the Workers
<br />Compensation Law of the states listed here: INDIANA
<br />B, Employers liability Insurance: Part Two of this policy applies to work in each state listed in Item 3A .
<br />The limits of our liability under Part Two are:
<br />Bodily Injury by Accident: $ 500,000 each accident
<br />Bodily Injury by Disease: $ 500,000 policy limit
<br />Bodily Injury by Disease: $ 500,000 each employee
<br />C. Other States Insurance: Part Three of this policy applies to the states, if any, listed here:
<br />All states except those listed in Item 3A of the Information Page and the following states or territories: AK, AL, CA, CO, DE, District of
<br />Columbia, FL, GA, ID, IL, KY, LA, MD, ME, MI, MT, NC, ND, NJ, NY, OH, OR, TX, UT, VT, WA, WI, WY, Puerto Rico and US Virgin Islands
<br />D. California Endorsements and Schedules
<br />Other State Endorsements and Schedules:
<br />IN-Notice-1, WCPYMSCH, WCOOOOOOC, WC000308, WC000404, WC000406A, WC000414, WC000419, WC00042ID, WC000422B,
<br />WC000425, MJWC1000, MPIL 1083, MPIL 1007
<br />4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All Information required is subject
<br />to verification and change by audit.
<br />Minimum Premium: $825,00 Deposit Premium:$608 00 Total Estimated Annual Premium:$4,056.00
<br />Pay plan: 10-Pay -15 %
<br />Producer:Holland Insurance Group LLC Countersigned By:
<br />54081 N Ironwood Rd, 574-277-0234
<br />South Bend, IN 46660 Date: 02/12/2018
<br />Servicing office: Markel Service, Inc., (888) 500-3344
<br />Central Park Plaza, 222 South 15th Street, Suite 150ON m ,,
<br />Omaha, NE 68102-1680
<br />See extension of information page for class code, rate and premium detail
<br />THIS INFORMATION PAGE WITH THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY AND
<br />ENDORSEMENTS, IF ANY ISSUED TO FORM A PART THEREOF, COMPLETES THE ABOVE NUMBERED POLICY
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