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<br />ND Fraud and Safety Hotline <br />1-800-243-3331 <br />Report Fraud and Unsafe WorK Conditions. <br /> <br />1600 EAST CENTURY AVENUE, SUITE 1 <br />PO BOX 5585 <br />BISMARCK ND 58506-5585 <br />TELEPHONE NUMBER (701) 328-3800 <br />FAX NUMBER (701) 328-3750 <br />TDD NUMBER (for the hearing impaired only) <br />(701) 328-3786 <br />www.WorkforceSafety.com <br /> <br /> <br />CERTIFICATE OF <br />PREMIUM PAYMENT <br />WORKFORCE SAFETY & INSURANCE <br />POLICYHOLDER SERVICES DIVISION <br />SFN 4920 (06/2003) <br /> <br />WSI Helpline <br />1-800-777-5033 <br />Questions? Call us. Re It In'urias Immediate! . <br /> <br />._. Workforce Safety <br />& Insurance <br />W S I Putting safety to work <br /> <br />ROBERT GIBB & SONS INC <br />PO BOX 10188 <br />FARGO ND 58106-0188 <br /> <br />Employer Account Number: 139121 <br /> <br />Issued Date: 02/05/2005 <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 of this certificate. <br /> <br />North Dakota Century Code S 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 />~ ~~~-.t(' <br /> <br />David Dvorak <br />Policyholder Services <br /> <br /> <br />5110 <br />5183 <br />5190A <br />6301 <br />8747 <br />8805 <br /> <br />Boi ler &Elevator -I nstallation -Svc <br />Plumbing-Htg-Sheet Metal <br />Electrical-Wiring-Svc- Repair <br />Sewer-Water-Gas-Pipeline Const <br />Professional/Business Reps <br />Clerical Office Employees <br />