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Worker's Compensation and Employer's Liability <br />JNDIANA <br />IFARM Insurance Policy <br />,♦® BUREAU INSURANCE® <br />Policy No. Transaction NEW BUSINESS <br />WC 8341646 00 <br />Policy Period <br />From 08/21/2022 to 08/21/2023 12:01 A.M. Standard Time at the address of the Insured as stated herein <br />Agent: Name and Phone Address !! <br />GALVAN, BRANDON 2410 EDISON RD, SUITE 400 i <br />574-400-4389 SOUTH BEND IN 46615-3518 <br />7601109762 <br />1. Named Insured and Address <br />NIEZGODSKI PLUM31NG, INC <br />232 N MAYFLOWER RD <br />SOUT�i BEND IN 46619-1534 <br />Carrier # <br />FEIN # <br />Risk ID # <br />Entity of Insured <br />16454 <br />199105098 <br />CORPORATION <br />Additional Locations: See Attached Schedule <br />2_ The Policy Period is from 08/21/2022 to 08/21/2023 12:01 a.m. Standard Time at the Insured's mailing address. <br />3. A. Workers Compensation Insurance: Part ONE of the policy applies to the Workers Compensation Law of the states <br />listed here: Indiana <br />B. 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: <br />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 />C. Other States Insurance: Part THREE of the policy applies to the states, if any, listed here: <br />ALL STATES EXCEPT states designated in item 3_A., North Dakota, Ohio, Washington, Wyoming <br />D. This policy includes these endorsements and schedules: See attached schedule. <br />4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans. <br />All information required below is subject to verification and change by audit. <br />SEE EXTENSION OF INFORMATION PAGE <br />Minimum Premium $ 582 Total Estimated Annual Premium $ <br />Expense Constant $ <br />Premium Discount $ <br />Premium Audit Period: ® Annual; ❑ Semiannual; ❑ Quarterly; ❑ Monthly <br />Countersigned: �,UGUST 22, 2022 <br />Issued Date: 08/23/2022 <br />8,084 <br />160 <br />0 <br />2%,7-�/ 7 / <br />Authorized Representative <br />Issuing Office: P_O. Box 1250; Indianapolis, IN 46206-1250 <br />WCPDEC 04ses INSURED <br />Page 1 of 2 <br />