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6.2.A. - Page 33 <br />WORKERS COMPENSATION AND El4jri.v a r -n i i.imomi i <br />INSURANCE POLICY —INFORMATION PAGE <br />_.... <br />Servicing Office: <br />Insurance for this coverage part provided by: <br />ZURICH AMERICAN INSURANCE <br />_.. —..._ ._ . _-_---_.__ ...... _ .. .. _...... <br />1, Policy Num berWC 4632830-0.5 <br />Named Insured and Mail Ing Address <br />:IRONWOOD ADVISORS, INC <br />270 ST PAUL #300 <br />DENVER CO 80206 <br />OMAHA <br />COMPANY 13 810 FNB PARKWAY <br />PO BOX 542003 <br />OMAHA, NE 68154 <br />�. ..W ............. ...... <br />Renewal <br />....._..........._. _........w...._..__. <br />Number WC 4632830-04 <br />Producer and Mailing Address <br />UNITED STATES INS SERVICES INC. <br />856 ELKRIDGE LANDING RD <br />LINTHICUM MD 21090-2903 <br />Producer Code 33988-000 <br />her workplaces not shown above: See Schedule of Locations <br />FEIN: 84-1455188 <br />NCCI Company No. 10863 ❑ New Q Renewal ❑ Rewrite of Prior Pollcy No. WC 4632830-04 <br />This information page, with policy provisions and endorsements, if any, completes this policy. <br />Insured is: CORPORATION <br />2. Policy Period: From: 06--01-20 15 to 06-01-2016 at 112:01 A. M. Standard Time at Insured'smailing address. <br />=Insured's Identification number(s): SeeSchedule Locations <br />S. A. Workers Compensatlon Insurance: Part One of the policy applies to the Workers' Compensation Lawof the states <br />listed here: <br />CALIFORNIA <br />B. Employers Liability Insurance: Part Two of the policy applies to work In each state listed In Item 3.A. <br />The limits of Ilabi[lty under Part Two are: Body Injury by Accident: 1,000,000 eachaccident <br />Bodily Injury by Disease: 1,000,000 policy limit <br />Bodily Injury by Disease: 1,000,000 eachemployee <br />C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: <br />ALL STATES EXCEPT ND, OH, WA, WY, AK, CO, HI AND THOSE STATES LISTED IN 3 <br />A. <br />D. This Policy Includes these Endorsements and Schedules: <br />See Schedule of Forms and Endorsements. <br />4. The premium forthis policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All <br />information required on the following Classification Schedule is subject to verification and change by audit. <br />See ClassfFication Schedule <br />TOTAL ESTIMATED STANDARD PREMIUM $ <br />PREMIUM DISCOUNT <br />$ <br />_ If indicated below, adjustment of premium shall <br />EXPENSE CONSTANT <br />$ <br />be made: <br />PREMIUM FOR ENDORSEMENT <br />$ <br />X❑ Annually <br />❑ Monthly <br />TAXES AND SURCHARGES <br />$ <br />' '` <br />El Semi Annually <br />ThisisaThree <br />❑ <br />TOTAL ESTIMATED ANNUAL PREMIUM <br />$ <br />year Fixed Rate <br />MINIMUM PREMIUM <br />$ <br />❑ Quarterly <br />Policy <br />DEPOSIT PREMIUM <br />$ <br />Agent or Producer <br />WC DO 0001 A <br />Countersigned by Resident Licensed Agent <br />Data <br />U WC -D-3 4-A (07-94) <br />Pago i of i <br />