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~~, ...._,. .. .~, .. . ." . <br />` RENEWAL <br />, .. - Standard Workers' Compensation and Employers' Liability Policy <br />INFORMATION PAGE For Policy No. A466787 118 <br />1. <br />Entity Insured: CORPORATION <br />COMSOURCE ASSOCIATES INC <br />747 WILLAMETTE ' <br />EUGENE OR 97401 <br />Other workplaces not shown above: <br />I nterested Parties <br />MCINTOSH ROBERT L <br />2. THE POLICY PERIOD i s from 04-01-92, 12:01 A.M. to 04-01-93, 12:01 A.M. , at the <br />insured's mailing address. <br />3. ( A. WORKERS COMPENSATION INSURANCE: PART ONE of the pol i cy appl i es to the <br />Workers' Compensation Law of the states listed here: OREGON <br />B. EMPLOYERS LIAB.ILITY INSURANCE: PART TWO of the policy applies to work in each <br />state listed in item 3.A. <br />The limits of our liability under Part Two are: <br />Bodily Injury by Accident $. 100,000 each accident <br />Bodily Injury by Disease $ 100,000 each employee <br />Bodily Injury by Disease $ 500,000 policv limit <br />C. OTHER STATES INSURANCE: PART THREE of the policy applies .to the states, if any <br />listed here: <br />D. THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES: <br />00 04 14 OWNERSHIP CHNGE 00 04 06 PREMIUM DISC 99 04 03 B GROUP SAFETY <br />99 04 02 B CLAIM RTG PLN 36 03 O1 OR UNSAFE EQUIP <br />4. TH E P REMIUM for this policy will be determined by our Manuals of Rules, Classifications, <br />Rates and Rating Plans. All information required below is subject to verification and <br />change by audit. <br />Classifications <br />OFFICE CLERICAL <br />Estimated Rate <br />Code Annual Per <br />Number Remuneration $100 <br />8810 I $116,115 I 0.63 <br />Subtotal <br />CRP F~ac: 0.95 ~Exp. Rated Premium: <br />Expense Constant: $85 ~Total Est. Annual Premium <br />Minimum Premium: ~500.00 <br />(continued on next pag2) <br />Estimated <br />Annual <br />Premium <br />$732 <br />$732 ~ <br />$695 <br />~780 <br />Standard Rates apply <br />400 High Street S.E. Salem, Oregon 97312-1000 <br />