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<br />
<br />CERTIFICATE OF
<br />FR~MIUM PAYMENT
<br />
<br />--
<br />
<br />1600 EAST CENTURY AVENUE. SUITE 1
<br />PO BOX 5585
<br />BI6MAR\J~ NIi ~~~7/-1m
<br />TW:PI-lOI-J~ NUM9~R (701) :J2g-J300
<br />FAX NUMBER (701) 328-3750
<br />TOO NUMBER(hearing impaired onlyj
<br />(701)328-3786
<br />WNW. WorkforceSafelv,corn
<br />
<br />W51 H~lpLin~
<br />j.666.m.~6M
<br />
<br />WORKFORCE SAFETY & INSURANCE
<br />POLICYHOLDER SERVICES DIVISION
<br />SFN 4920 (0612003)
<br />
<br />Questions? Call us. RDport injuries immeo'ilt,,;y
<br />ND Fraud.and Safety Hotline
<br />'.800-243-3331
<br />Rllport Fraud ancl Umale Worl<Ccl1diliollS
<br />
<br />~, Workforce Safety
<br />..~~ & Insurance
<br />W S I I'II/ting .",jer)' 10 ...ork
<br />
<br />Michael Wolf
<br />ND Association of Counties I
<br />1661 CapilolWay
<br />Bismarck, ND 58501-6600
<br />
<br />Employer Account Number: 1196351
<br />Issued Date: 3/13/06
<br />Expiration Date: 3/16/07
<br />
<br />CERTIFICATE OF PREMIUM PAYMENT
<br />
<br />ThiS is to certify that North Dakota Workers Compensation coverage is effective for the em!Jloyer named on this certificate.
<br />Employees of the named employer are entitled to apply for the rights and benefits of Workforce Safety and 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 Sec. 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 premium
<br />charge for all accounts Is $125 per year.
<br />
<br />~ ~vc~~
<br />
<br />David Dvorak, Policyholder Services Director
<br />
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<br />Consulting Engineers
<br />Street And Hwy Const-Maintenance
<br />Chauffeurs-School Bus-Ambul
<br />WatelWorks
<br />Fire Depls-Paid Empioyees
<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-! n stitutions
<br />Restaurants And Lounaes
<br />Amusement Parks/Park Boar
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<br />0010 Z
<br />3630 Z
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