HomeMy WebLinkAboutWC POLICY (Policy Provisions: WC000000C)
INFORMATION PAGE
WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY
INSURER:Hartford Accident and Indemnity Company
ONE HARTFORD PLAZA HARTFORD CT 06155
lurTHE
HARTFORD
NCCI Company Number: 110448
Company Code:5
Suffix
LARS RENEWAL
POLICY NUMBER: 08 WEC AY9G9D 2
Previous Policy Number: 08 WEC AY909D
1. Named Insured and Mailing Address: GIARDINO'S TASTEE TOWER,INC
(No.,Street,Town,State,Zip Code) 242 MAIN ST
WEST YARMOUTH MA 02673
FEIN Number: 04-2490039
State Identification Number(s):
The Named Insured is: Corporation
Business of Named Insured: Full-Service Restaurants
Other workplaces not shown above:242 Main St
West Yarmouth MA 02873
Z Policy Period: From 09/01/24 To 09/01/25 ANNUAL.
12:01 a.m.,Standard time at the insured's mailing address.
/►oda.'w's Name: AXIA INSURANCE SERVICES INC
84 MYRON ST STE A
WEST SPRINGFIELD MA 01099
Producer's Code: 08088030
Isodne O*sr. THE HARTFORD BUSINESS SERVICE CENTER
3600 WISEMAN BLVD
SAN ANTONIO TX 78251
(866)467-8730
Total Estimated Annual Premium: $3,194
Deposit Premium:
Policy Minimum Premium: $531 MA(Includes Increased Limit Min.Prem.)
Audit Period:ANNUAL Installment Term:Full Pay(100%Down)
The policy is not binding unless countersigned by our authorized representative.
Countersigned by J� `b � 07/23/24
Authorized Representative Date
Form WC 00 00 01 A (1) Printed in U.S.A. Pape 1 (Continued on next page)
Process Date: 07/23/24 Policy Expiration Dale 09/01/25
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