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INDIANA FARM <br />rat BUREAU INSURANCE@ <br />Worker's Compensation and Employer's liability <br />Insurance Policy <br />Poli No. Transaction RENEWAL BUSINESS <br />W 8341646 02 <br />Policy Period <br />From 0 8 / 21 / 2 0 2 4 to 0 8 / 21 / 2 0 2 5 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 BEND IN 46615-3518 <br />7601102 762 <br />1. Named Insured and Address <br />NIEZGODSKI PLUMBING, INC <br />232 N MAYFLOWER RD <br />SOUTH BEND IN 46619-1534 <br />Carrier# <br />FEIN # <br />Risk ID # <br />Entity of insured <br />16454 <br />19910SO98 <br />CORPORATION <br />Additional Locations: See Attached Schedule <br />2. The Policy Period is from 08/21/2024 to 08/21/2025 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, it 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 $ 488 Total Estimated Annual Premium $ <br />Expense Constant $ <br />Premium Discount $ <br />Premium Audit Period: ® Annual; ❑ Semiannual; ❑ Ouarterly; ❑ Monthly <br />Countersigned: DUNE 12 , 2024 <br />Issued Date: 06/13/2024 <br />Issuing Office: P.O. Box 1250; Indianapolis, IN 46206-1250 <br />9,613 <br />160 <br />0 <br />�J <br />Authorized epresentative <br />WCPCEc 04s4 INSURED 00121-00003 Paae 1 of 3 <br />