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<br />., P.-.-....,..~.\ <br />11i./f"#~':::.:~."':::~~) ,\\ <br />I 'I". .c" iJ <br />~\ ~'1li <br />';......~ .&:/. <br />~~9~ <br /> <br />PREMIUM PAYMENT <br />WORKFORCE SAFETY & INSURANCE <br />POLICYHOLDER SERVICES DIVISION <br />SFN 4920 (06/2003) <br /> <br />--.-- <br />..-. . .""'.....-....... <br />1.8oo-7n -5033 <br />Questions? Call us. R rt In.uriea Immedlat <br /> <br />NO Fraud and Safety Hotlfne <br />1.800-243-3331 <br />Report Fraud and Unsafe Work Conditions. <br /> <br /> <br />t'U tlUJI. oblSo <br />BISMARCK ND 58506-5585 <br />TELEPHONE NUMBER (701) 328-3800 <br />FAX NUMBER (701) 328-3750 <br />TOD NUMBER (for the hearing impaired only) <br />(701) 328-3786 <br />www.WorkforceSafety.com <br /> <br />. Workforce Safety <br />." & Insurance <br />W S I Putting safety to work <br /> <br />ALL TERRAIN GROUNDS MAINTENANCE INC <br />3542 46TH AVE S <br />FARGO NO 58104-6681 <br /> <br />Employer Account Number: 1261163 <br /> <br />Issued Date: 09/13/2004 <br /> <br />Expiration Date: 10/14/2005 <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 9 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 />~ ~~~-J(' <br /> <br />David Dvorak <br />Vice President, Policyholder Services <br /> <br />Class Classification Description <br />6042 Street & Hwy Const-Maintenance <br />9007 Bldg Custodians - Janitorial <br />