Laserfiche WebLink
<br />:~_,:?t~t.,'" <br />"""l~"" <br />:,:;!.~~} <br /> <br />I"C~llrlu~1 C vr <br />PREMIUM PAYMENT <br />WORKFORCE SAFETY & INSURANCE <br />EMPLOYER SERVICES DIVISION <br />SFN 4920 (06/2003) <br /> <br />WSI HelpLine <br />1-800-777-5033 <br />O"e~lions? CaOl U~ ~epOr: l"lu~es Imfllet:!':l1l>I.... <br /> <br />PO BOX 5585 <br />BISMARCK NO 58506.5585 <br />TELEPHONE NUMBER (701) 328.3600 <br />FAX NUMBER (701)326-3750 <br />TOO NUMBER (for the hearing impaired only) <br />(701) 326-3786 <br />www.WorkforceSafety.com <br /> <br />r <br />'I NO Fraud and Safety Hotline <br />1.800.243-3331 <br />! ReODIT Frau(1 ana Unsafe Work CondiliDllS <br /> <br />., <br />WSI <br /> <br />Workforce Safety <br />& Insurance <br />PUlling safery /0 work <br /> <br />SPRINGER DANIEL C PRESIDENT <br />TRI STATE STRIPING <br />30511TH STW <br />WEST FARGO ND 58078-1400 <br /> <br />Employer Account Number: 960187 <br /> <br />Issued Date: 02/08/2006 <br /> <br />Expiration Date: 04/16/2007 <br /> <br />CERTIFICATE OF PREMIUM PAYMENT <br /> <br />This ;s 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 />C)%2~ <br /> <br />Jody Mailing <br />Employer Services Director <br /> <br />Class Classification Description . <br />3630X Optional Coverage <br />6042N Hwy Traffic Signal-Lighting J <br />6042X Optional Coverage <br />8747 Professional/Business Reps <br />8805 Clerical Office Employees <br />