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CITY OF SUNNY ISLES BEACH <br /> WN@101N6 PROFESSIONAL AR®TECITRAL&EN61NIER11V6 SERVICES MRS ONLY(COM 0.' <br /> ® REQUEST FOR QUALIFICATIONS NO.12-04-02 <br /> TRAVELERS J WORKERS COMPENSATION <br /> AND <br /> EMPLOYERS LIABILITY POLICY <br /> TYPE V INFORMATION PAGE WC 00 00 01 ( A) <br /> POLICY NUMBER: (IDTEHUB-638M363-8-11 ) <br /> NEW-11 <br /> INSURER: THE TRAVELERS INDEMNITY COMPANY OF AMERICA <br /> 1 NCCI CO CODE: 13439 <br /> INSURED: PRODUCER: <br /> R.J. BEHAR 8 COMPANY INC AUTOMATIC DATA PROC INS <br /> 6861 SW 196TH AVE #302 71 HANOVER RD <br /> FORT LAUDERDALE FL 33332 FLORHAM PARK NJ 07932 <br /> Insured is A CORPORATION <br /> Other work places and identification numbers are shown in the schedule(s) attached. <br /> 2. The policy period is from 01-01-11 to 01-01-12 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 /> FL <br /> B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work In each state listed in <br /> Item 3.A. The limits of our liability under Part Two are: <br /> Bodily Injury by Accident: $ 1000000 Each Accident <br /> Bodily Injury by Disease: S 1000000 Policy Limit <br /> Bodily Injury by Disease: $ 1000000 Each Employee <br /> C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: <br /> AL AR AZ CA CO CT DC DE GA HI IA ID IL IN KS KY LA MA MD ME MI MN <br /> MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI <br /> WV <br /> C— <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 ANNUALLY. <br /> mmr <br /> DATE OF ISSUE: 01 -04-11 AD <br /> ® OFFICE: PAYROLL 70A <br /> PRODUCER: AUTOMATIC DATA PROC INS XV770 <br /> a 13253 <br /> ®1 R.J.Behar SECTION 1 - PAGE 13 <br />