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<br />NO Fraud and Safety Hotline <br />1-800-243--3331 <br />Report fraud and Unsafe Work Condl~ons. <br /> <br /> <br />@002 <br /> <br />1600 EAST CENTURY AVENUE. SUITE 1 <br />PO BOX 5585 <br />BISMARCK ND 58506-5585 . <br />TELEPHOr-IE NUMBER (701) 328-3800 <br />FP.x NUMBER (701) 328-3750 <br />TDD NUMBER (for the hearing impaired only) <br />(701) 328-3786 <br />www.WorkforceSafety.com <br /> <br />03/17/05 TaU 08:19 FAX 701 241 5728 <br /> <br />CASS COUNTY COURTHOUSE <br /> <br /> <br />CERTIFICATE OF <br />PREMIUM PAYMENT <br />WORKFORCE SAFETY & INSURANCE <br />POLICYHOLDER SERVICES DIVIS10N <br />SFN 4920 (06/2003) <br /> <br />WSI HelpLine <br />1-800-777-5033 <br />Questions( Call us.. RePQrt In.uries lmmedlat <br /> <br />. Workforce Safety <br />.. & Insurance <br />. W S I . Putting safety to work <br /> <br />MIKE WOLF <br />NO ASSOCIATION OF COUNTIES INC <br />1661 CAPITOL WAY SUITE 100 <br />BISMARCK ND 58501-5600 <br /> <br />Employer Account Number: 1196:351 <br /> <br />Issued Date: 03/10/2005 <br /> <br />Expiration Date: 03/16/2006 <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 ofthis 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 paymE!nts. <br />premium charge for all accounts is $125 per year. <br /> <br />The minimum <br />; <br /> <br />~~~~ <br /> <br />David Dvorak <br />Policyholder Services <br /> <br /> <br /> <br />f!r~!~~~1~~~~~1H;:~~~11r~~~~!~;j'~~~&~.~{J~ <br />. . . . <br /> <br />0003Z <br />0010Z <br />36302 <br />56032 <br />6042Z <br />7380Z <br />7520Z <br />77002 <br />7715Z <br />77202- <br />87472 <br />8805Z <br />9002Z <br />90072 <br />90402 <br />90422 <br />90622 <br />90712 <br />9182Z <br />I 9403Z <br /> <br />Florists-Nurseries-Gardening Operations <br />Poisoning And'Spraying <br />Auto Repair-BodLShops-Mech <br />Consulting Engineers <br />Street And Hwy Const-Maintenance <br />Chauffeurs-School Bus-Am bul <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 />Schools-Libraries-Institutions <br />Restaurants And Lounges <br />Amusement Parks/Park Boar <br />Sanitation Operations <br />