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<br />WORKERS COIItIl-'ENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br /> <br />Insurer: FCCI INSURANCE COMPANY <br />6300 UNIVERSITY PKWY <br />SARASOTA, FL 34240-8424 <br /> <br />Ca~erNumbe~ 24570 <br />Policy Number: 001-WC10A-39871 <br />Prior Policy Number: 001-WC09A-39871 <br /> <br />INFORMATION PAGE <br /> <br />1. The Insured: KEEFE MCCULLOUGH & CO LLP <br /> <br />Mailing Address: 6550 N FEDERAL HWY STE 410 <br />FORT LAUDERDALE, FL 33308-1417 <br /> <br />Business Status: Partnership <br /> <br />Risk ID Number: 091430207 <br /> <br />FEIN Number: 591363792 <br /> <br />Other workplaces not shown above: <br /> <br />2. The policy period is from 01/01/10 12:01 AM to 01/01/11 12:01 AM at the Insured's Mailing Address. <br /> <br />3. A. Workers' Compensation Insurance: Part One of the policy applies to the Workers' Compensation law of the <br />state(s) listed here: FLORIDA <br /> <br />B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The <br />limits of our liability under Part Two are: <br />Bodily Injury by Accident $100,000 each accident <br />Bodily Injury by Disease $500,000 policy limit <br />Bodily Injury by Disease $100,000 each employee <br /> <br />C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: <br />All states and U.S. terrltories except North Dakota, Ohio, Washington, <br />Wyoming, Puerto Rico, the U.S. Virgin Islands, and <br />states designated in Item 3.A. of the Information Page. <br />D. This policy includes these endorsements and schedules: wcoooooo A( 4/92) WC000001 A( 5/88) <br />WC000308 WC000414 WC000419 WC090303 <br />WC090403 A WC090606 WC990602 (5-97) WC990609 <br /> <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 /> <br />SEE EXTENSION OF INFORMATION PAGE <br /> <br />Total Estimated Policy Premium: $4,613 <br />Minimum Premium: $220 <br />Program Type: Gold Advantage Plan <br />Agency Name: 320, Plastridge/Delray Beach <br />Agency Location: Delray Beach, FL <br />Agency Phone Number: (561) 276-5221 <br /> <br />ft:!- <br /> <br />President <br /> <br />Countersigned by <br /> <br />Authorized Representative <br /> <br />we 00 00 01 A <br />Copyright 1987 National Council on Compensation Insurance <br />EZ0108, Rev. 4/99 Page 1 <br />