Laserfiche WebLink
AMRINDIANA FARM <br />BUREAU INSURANCE@ <br />WORKERS COMP 8 EMPLOYERS LIABILITY <br />Policy No. <br />WC 8341646 00 <br />Policy Period <br />From 08 /21 /2022 to 08/21/2023 at 12:01 a.m. Standard Time at the described 10cation <br />EXTENSION OF INFORMATION PAGE <br />CLASSIFICATION OF OPERATIONS <br />Code <br />No, Classification Description <br />Premium Basis <br />Total Est. Annual <br />Remuneration <br />Rate Per <br />$100 of <br />Remuneration <br />Estimated <br />Annual <br />Premium <br />Indiana <br />Rating Period 08/2/12022 through 08/21/2023 <br />Site 00001 <br />5183 PLUMBING NOC & DRIVERS <br />645,931 <br />1_670000 <br />10,787.00 <br />8810 CLERICAL OFFICE EMPLOYEES - NOC <br />100,000 <br />0_120000 <br />120_00 <br />Site 00001 Total <br />S <br />10 , 907 _ 00 <br />Total of Sites for Rating Period <br />$ <br />10,907.00 <br />Rating Period Total <br />Rating Period 08/21/2022 through 08/21/2023 <br />9812 EMPLOYER'S T.TABILITY INCREASED LIMITS <br />10,907 <br />0_028000 <br />305_00 <br />9898 EXPERIENCE MODTFICATION 085 <br />11,212 <br />-0-140000 <br />-1,570.00 <br />9687 SCHEDULE RATING CREDIT <br />9,642 <br />-0.200000 <br />-1,928.00 <br />160-00 <br />0900 EXPENSE CONSTANT <br />0935 STATE ASSESSMENT/SECOND INSURY FUND <br />8,024 <br />0.007500 <br />60, 00 <br />9740 TERRORISM <br />745,931 <br />0.0TQ000 <br />7S_00 <br />9741 C2ITASTROPHE-OTHER TkiRN CERTIFIED ACTS OF <br />TERRORISM 745,931 <br />0.01000Q <br />75-00 <br />$ <br />-2 , 823 _ 00 <br />Rating Period Total <br />Total of all NON -SPLIT Classes <br />$ <br />-2 , 823 . 00 <br />$ <br />10 , 907 _ 00 <br />Total of all SPLIT Classes <br />State Total <br />$ <br />8 , 084 _ 00 <br />Policy Total <br />$ <br />a , 084 _ 00 <br />Issued [Date: 06/23/2022 <br />wcPbec o�07 IN SU REF Paue 2 of 3 <br />