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Milwaukee Casualty Insurance Company A Stock Insurance Company WORKERS COMPENSATION We 99 0001 8 AND EMPLOYERS LABILITY tots INSURANCE POLICY INFORMATION PAGE Neci Code: 69103 1. Insured: Policy Number: MWC1010274 Masada Charter School Inc, PobooetT Colorado City, AZ 86021 _ Individual _ Partnership. Cuber workplaces nt shown above: CoE wea ssn nemo Pas Sener ene ars Aco ei es 1350 E SOUTHERN AVE MBSA, AZ 85204 v ‘The policy period is from 8/1/2015 to 8/1/2016 12:01 am. atthe insured’s mailing address, ‘A. Workers Compensation Insurance: Part One of the poliey applies to the Workers Compensation Law of the states listed here: Arizona B, Employers Liability Insurance: Part Two of the policy applies to workin each state listed in item 3.A. ‘The limits of our ability under Part Two are State__Bodily Injury by Accident _ _Bodily Injury by Disease__Bodily Injury by Disease '$500,000 each accident $500,000 poliey limit '$500,000 each employee (Other States Insurance: Part Three ofthe policy applies tothe states, if any, listed here: All states except ND, OH, WA, WY and State(6) Designated in Item 3, D_Thispolicy inchudes these endorsements and schedules: See Extension of Information Page ‘The premium for this poliey will be determined by our Manuals of Rules, Classifications, Rates and Rating. Plans, ll information required below is subject to verification andl change by audit ‘See Extension of Information Page ‘TOTAL ESTIMATED ANNUAL PREMIUM 10,005 STATE ASSESSMENT 0 ‘TOTAL ESTIMATED COST 10,005 Minimum Premium 724 Deposit Premium 10,005 Issue Date: 8/13/2015 ‘Countersigned by ‘Authorized Representative