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U~-11-92 U~:3fiYM F~UM CAMERON & McCARIHY PUl <br />LIBfiRTY NORTHWFSI' INSURANCE CORPORATION - 2t7300 <br />WORKERS COMPENSATION AND EMPLOYBRS'LIABILiTY INSURANCE POLICY <br />HOUte Aetount: Ht~IE OFFICE-EUGENE , 8098 / R•n•w.l <br />AQE .. . . ... <br />Statug PARTNERBH I P Risk Id No. bN4 <br />Folicp Nawc4-tHC-e2o2~a-o~ i TD/CD a~~4 SFXII: R03 <br />1. TheInsured: AItAN R CAMERON 8 BRIAN D MCCAAtkY <br />DHA: CAMERON Q MCCARTtIY lANOBCAPE ARCHITECTS <br />Meil~ng Addr~s9' t410 oAK ST STE ~OC <br />EU(iENE OR 07401 <br />Other workplacea not sl~own abuvo; <br />1. The polity period ia from 10/01/91 to 10/01/92 12:01 a.m. atandard time <br />st the sddresa of the inaured a~ riated above: <br />3. A. Wvrkere Compensation Insuranca Pnrt One of the policy applies to the Workers <br />Compoaaatlon Law of the atates liated hera OREOON <br />B. Fmplnyen LiebilitJ Insurence: Part T~vo of the policy applies to work in eaeh state <br />listrd in it~m 3.A. Th~ limita of our liability nader Part Two are: <br />Bodilq Injury by Accident t1G0,000 each accident <br />Aodilr InJuty br n~e~9e ~e00,000 pulicy limi~ <br />BoclIlq In3nrq by DiseasE+ ~too,ooo ~aeh ~mploy~a <br />C. Other Stetes Insuranca Pert Thra of tho policy ap liea to the atatea, if eny, listed Itete: <br />A]I atate~ e:cept nhin, N~reh nAkot~, w~,hin~to~. ~tPOSa~, w~t vir$;n;a, wyo~in~ <br />4. 'I'h~ promiu~n for 4hie poliey aill be determiaed by oar Mnnnnls of Rulos, Clnssificatioas, Rstea <br />end Ratinq Plany All Information shown on atteehed eztenaien achpdnie i~ ~uhj~t to <br />verification and cbange b' eudil. <br />Bxpense Constanx S ~oo Reporting Prequency: Annu. i iy <br />D~poait Pr~miasn: S Minimum Premium: S 300 <br />Total Estimalecl Annual Premium: ~664 <br />Counteraigned: 20 f~~l ~ , ~,G' <br />V~1..7~~~L~ ~ ~ f~j~fM~ <br />Endoraements WC ~0 03 O1 , WC 36 00 01 , WC 00 04 14, WC 99 04 23 , WC 99 00 18 <br />WC 00 03 08 <br />10l11/o1'~H <br />WC000001 <br />LNVV 3011 <br />Past.l '" brc+nd fax trAnamlttal ma 7671 Nof oa9aa - <br /> F rn <br />Co. • <br />p~p~_ Phons # <br />Fel[ 4 Fes N <br />