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WORKERS COIvirENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br /> Insurer: FCCI INSURANCE COMPANY Carrier Number: 24570 <br /> 6300 UNIVERSITY PKWY Policy Number: 001-WC10A-39871 <br /> SARASOTA, FL 34240-8424 Prior Policy Number: 001-WCO9A-39871 <br /> INFORMATION PAGE <br /> 1. The Insured: KEEFE MCCULLOUGH & CO LLP <br /> Mailing Address: 6550 N FEDERAL HWY STE 410 <br /> FORT LAUDERDALE, FL 33308-1417 <br /> Business Status: Partnership <br /> Risk ID Number: 091430207 FEIN Number: 591363792 <br /> Other workplaces not shown above: <br /> 2. The policy period is from 01/01/10 12:01 AM to 01/01/11 12:01 AM at the Insured's Mailing Address. <br /> 3. A. Workers' Compensation Insurance: Part One of the policy applies to the Workers' Compensation law of the <br /> state(s) listed here: FLORIDA <br /> B. Employers b" <br /> Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The <br /> limits of our liability under Part Two are: <br /> Bodily Injury by Accident $100,000 each accident <br /> Bodily Injury by Disease $500,000 policy limit <br /> Bodily Injury by Disease $100,000 each employee <br /> C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: <br /> All states and U.S. territories except North Dakota, Ohio, Washington, <br /> Wyoming, Puerto Rico, the U.S. Virgin Islands, and <br /> states designated in Item 3.A. of the Information Page. <br /> D. This policy includes these endorsements and schedules: WC000000 A(4/92 ) W0000001 A(5/98) <br /> W0000308 WC000414 WC000419 WC090303 <br /> WC090403 A WC090606 WC990602 (5-97) WC990609 <br /> 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. <br /> All information required below is subject to verification and change by audit. <br /> SEE EXTENSION OF INFORMATION PAGE <br /> Total Estimated Policy Premium: $4,613 <br /> Minimum Premium: $220 <br /> Program Type: Gold Advantage Plan G . Jacobs <br /> Agency Name: 320, Plastridge/Delray Beach President <br /> Agency Location: Delray Beach, FL <br /> Agency Phone Number: (561) 276-5221 <br /> Countersigned by <br /> Authorized Representative <br /> WC000001 A <br /> Copyright 1987 National Council on Compensation Insurance <br /> EZ0108, Rev. 4/99 Page 1 <br />