HomeMy WebLinkAboutWC 41123 WORKERS COMPENSATION AND EMPLOYERS'LIABILTY
INSURANCE POLICY—INFORMATION PAGE
INSURER: POLICY NO: WE114835A
NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY
222 AMES STREET RENEWAL
DEDHAM, MA 02026 R
E C F I V C NCCI Company No: 21059
D
Account No:
} IAPR11 2023 FEIN: 26-1913272
UJI DI
ITEM 1, NAMED INSURED AND MAILING AD ESS�NG DEPARTMENT AGENT NAME AND ADDRESS:
PARKERS RIVER RESORT LLC ROGERSGRAY
759 MAIN STREET 410 UNIVERSITY AVE
SOUTH YARMOUTH, MA 02664 WESTWOOD, MA 02090
AGENT NO.: 20577
LEGAL ENTITY: LIMITED LIABILITY COMPANY (LLC)
OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Schedule)
ITEM 2. POLICY PERIOD: From: 05/18/2022 To: 05/18/2023
Effective 12:01 A.M. Standard Time at the Insured's mailing address.
ITEM 3. COVERAGE:
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
states listed here:
MA
B. Employers'Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits
of liability under Part Two are:
Bodily Injury by Accident: $ 500,000 each accident
Bodily Injury by Disease: $ 500,000 policy limit
Bodily Injury by Disease: $ 500,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any,listed here:
SEE ENDORSEMENT WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules:
See Schedule of Forms and Endorsements.
ITEM 4. PREMIUM:The premium for this Policy will be determined by our Manuals of Rules,Classifications, Rates and
Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to
verification and change by audit.
Total Estimated
Minimum Premium: $ 226 Annual Premium: $ 363
Audit Period: SAL Additional/Return Premium:
Comments:
Issued At:
Date: 04/08/2022 Countersigned by
WC 00 00 01 A Copyright 1987 National Council on Compensation insurance