Laserfiche WebLink
<br /> <br />PREMIUM PAYMENT <br />WORKFORCE SAFETY & INSURANCE <br />POLICYHOLDER SERVICES DIVISION <br />SFN 4920 (0612003) <br /> <br />..VI "'1111IJo1&"II'O <br />. r 1-8OO.7n,.S()33 <br />, OvntIoI1ll? Call UI. 111 urla Immldal <br /> <br />NO Fraud and S.fety HoUlne <br />1-800-243-3331 <br />Report Fraud and Unsafe WOItt CondIuon.. <br /> <br />PO BOX 5585 <br />BISMARCK NO 58506-5585 <br />TELEPHONE NUMBER (701) 328-3800 <br />FAX NUMBER (701) 328-3750 <br />TOO NUMeER (for the hearing impaired only) <br />(701) 328-3786 <br />www.WorldorceSafety.com <br /> <br />._. Workforce Safety <br />& Insurance <br />W S I Putting safety to work <br /> <br />DAKOTA ELECTRIC CONST CO INC <br />1550 1ST AVE N <br />FARGO ND 58102-4275 <br /> <br />Employer Account Number: 312793 <br /> <br />Issued Date: 08/25/2005 <br /> <br />Expiration Date: 09/13/2006 <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 !l 65-04-04 requires that each employer post this Certificate of Premium Payment in a <br />conspicuous manner at the workpiace. A penally 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 />~ '::la ~.~ _..(' <br /> <br />David Dvorak <br />Policyholder Services Director <br /> <br /> <br />'r~~%~!.I.!<,:;).~,.,..,li'iif:,;' 1_.i.'C:"I"'aN~s':;,o.s" "I.f'" c,:"ia.'t1"o'.I'n'~-D"'; ';e"s~~cr'l' 'j;I'o"~n'~.f.' ,. ,l1!~'N8:~!f(~;t_m~;~:t.1'r;1~~.n'~~riJ'lFioj'~~fe' ,:l,. <br />.Wtt"7J..',':,~..;;:,-WL "..~,....,...._.t...,-.-" ~.."" ,.-\_... .,,,.,,.....P..L...., ' ,,~ ~~~(~,m.:it;!:ilPr~!~l'i..4J~;}<15;,~\l!I~. , <br /> <br /> <br />,._~'-~..,,,..,.._......".-- <br />'N"'" 'M~ <br />",.,,;::.; ..'I$4:.:i.'r05~ <br /> <br />5190A <br />5190X <br />6605 <br /> <br />Electrlcal-Wiring-Svc-Repair <br />Optional Coverage <br />Clerical Office Employees <br />