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<br /> <br />CERTIFICATE OF <br />PREMIUM PAYMENT <br />WORKFORCE SAFETY & INSURANCE <br />POLICYHOLDER SERVICES DIVISION <br />SFN 4920 (06/2003) <br /> <br />WSI HelpUne <br />1-800-777-5033 <br />Questions? Call us, ReDort In'uries Immediate, <br /> <br />NO Fraud and Safety Hotline <br />1-800-243-3331 <br />Report Fraud and Unsafe Work Conditions. <br /> <br /> <br />1600 EAST CENTURY AVENUE. SUITE 1 <br />PO BOX 5585 <br />BISMARCK NO 58506-5585 <br />TELEPHONE NUMBER (701) 328-3800 <br />FAX NUMBER (701) 328-3750 <br />TOO NUMBER (for the hearing impaired only) <br />(701) 328-3786 <br />WWV'/. W orkforceSafety,com <br /> <br /> <br />Workforce Safety <br />& Insurance <br />Putting safety to work <br /> <br />MIKE WOLF <br />NO ASSOCIATION OF COUNTIES INC <br />1661 CAPITOL WAY <br />BISMARCK NO 58501-2195 <br /> <br />Employer Account Number: 1196351 <br />Issued Date: 03/01/2004 <br />Expiration Date: 03/16/2005 <br /> <br />CERTIFICATE OF PREMIUM PAYMENT <br /> <br />This is to certify that North Dakota Workers Compensation coverage is effective for the employer named on this <br />certificate. Employees of the named employer are entitled to apply for the rights and benefits of Workforce Safety and <br />Insurance. <br /> <br />Coverage under this certificate extends to North Dakota based employers for their North Dakota exposure. Limited <br />coverage extends beyond the physical boundaries of North Dakota. Contact the Policyholder Services Department of <br />Workforce Safety and Insurance at 1-800-777-5033 for further information on coverage issues or to inquire into the status <br />of the holder of this certificate. <br /> <br />North Dakota Century Code § 65-04-04 requires that each employer post this Certificate of Premium Payment in a <br />conspicuous manner at the workplace. A penalty of $250 may apply for failure to comply with this requirement. <br /> <br />A certificate of premium payment may be revoked for failure to make required premium payments. The minimum <br />premium charge for all accounts is $125 per year. <br /> <br />.~ ~ ~-~ <br /> <br />David Dvorak <br />Vice President, Policyholder Services <br /> <br /> <br />00032 <br />00102 <br />3630Z <br />5603Z <br />60422 <br />73802 <br />75202 <br />77002 <br />77152 <br />77202 <br />87472 <br />88052 <br />90022 <br />90072 <br />90402 <br />90422 <br />90622 <br />90712 <br />91822 <br />94032 <br /> <br />Florists-Nurseries-Gardening Operations <br />Poisoning And Spraying <br />Auto Repair-BodLShops-Mech <br />Consulting Engineers - <br />Street And Hwy Canst-Maintenance <br />Chauffeurs-School Bus-Ambul <br />Waterworks <br />Fire Depts-Paid Employees <br />Civil Defense Emerg Trainees <br />Law Enforcement <br />Traveling Representatives <br />Clerical Office Employees <br />Domestics <br />Bldg Custodians- Janitorial <br />Hospitals <br />Med Clinics-Physicians-Dentists <br />Schoo Is-Libraries-I nstitutions <br />Restaurants And Lounges <br />Amusement Parks/Park Boar <br />Sanitation Operations <br />