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09/18/2009 13:44 5416893 <br />TRAVELERS <br />Al' <br />INSURER: THE TRAVELERS INDEMNITY COMPANY <br />POLICY NUMBER: (6KUB-9827M61 -6-09 ) <br />NEW-09 <br />m- <br />d <br />m= <br />o= <br />o....., <br />o= <br />o~ <br />o~ <br />o~ <br />[TIIII <br />1. <br />INSURED: <br />CROCKETTS INTERSTATE TOWING <br />& TRANSPORT <br />P.O. BOX 11341 <br />EUGENE OR 97440 <br />Insured IS A CORPORATION <br />T AND TOWING • PAGE 01/01 <br />WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />TYPE AR INFORMATION PAGE WC 00 00 01 ( A) <br />PRODUCER: <br />NCCI CO CODE: 11347 <br />NONE <br />POLICY SERVICED AT: <br />2420 LAKEMONT AVE. <br />ORLANDO FL 32814 <br />Other work places and Identification numbers are shown in the schedule(s) attached. <br />2. The policy period Is from 07-09-09 to 07-09-10 12:01 A.M. at the Insured's mailing address. <br />3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers <br />Compensation Law of the state(s) listed here: <br />OR <br />B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed In <br />item S.A. The limits of our liability under Part Two are: <br />Bodily Injury by Accident: $ 500000 Each Accident <br />Bodily Injury by Disease: $ 500000 Policy Limit <br />Bodily Injury by Disease: $ 500000 Each Employee <br />C. OTHER STATES INSURANCE: Pan Three of the policy applies to the states, N any, listed here: <br />COVERAGE EXCLUDED - REFER TO RESIDUAL MARKET LIMITED OTHER STATES <br />INSURANCE ENDORSEMENT WC 00 03 26 <br />D. This policy includes these endorsements and schedules: <br />SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE <br />4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating <br />Plans. All required Information is subject to verification and change by audit to be made SEMI ANNUALLY . <br />DATE OF ISSUE: 08-12-09 JT <br />OFFICE: ST LOUIS/NCCI <br />PRODUCER: NONE <br />Oil <br />22LMU <br />ST ASSIGN: OR <br />