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INDIANA FARM <br />P&M BUREAU INSURANCEID <br />Worker's Compensation and Employer's Liability <br />Insurance Policy <br />Policyp No. Transaction AMENDED DECLARATIONS Effective: 0 8 / 21 / 2 0 2 3 <br />WC ii341646 01 CHANGE COVERAGE <br />Policy Period <br />From 0 S / 21 / 2 0 2 3 to 0 8 / 21 / 2 0 2 4 12:01 A.M. Standard Time at the address of the insured as stated herein <br />Agent: Name and Phone Address <br />JACOB KELLEY 2410 EDISON RD, SUITE 400 <br />574-400-4389 SOUTH SEND IN 46615-3518 <br />7601102 762 <br />1. Named Insured and Address <br />NIEZCODSKI PLUMBING, INC <br />232 N MAYFLOWER RD <br />SOUTH BEND IN 46619-1534 <br />Carrie r# <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 0 8 / 21 / 2 0 2 3 to 0 8 / 21 / 2 0 2 4 12:01 a. m. Standard Time at the I nsured'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 <br />$ <br />1,000,000 <br />each accident <br />Bodily Injury by Disease <br />$ <br />1, 000, 000 <br />policy limit <br />Bodily Injury by Disease <br />$ <br />1,000,000 <br />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 $ 538 Total Estimated Annual Premium $ <br />Expense Constant $ <br />Premium Discount $ <br />Premium Audit Period: ® Annual; ❑ Semiannual; ❑ Quarterly; ❑ Monthly <br />Countersigned: NOVEMBER 13, 2023 <br />Issued Date: 11/14/2023 <br />Issuing Office: P.O, Box 1250; Indianapolis, IN 46206-1250 <br />10,779 <br />160 <br />-31 <br />D,: 7� 7 /w, 4 � r, <br />Autl onze epresentative <br />WCPDEC 04s4 INSURED 00267-00003 Page 1 of 4 <br />