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<br />04-27-06 14:02 <br /> <br />From-WORKFORCE SAFETY AND INSURANCE <br /> <br />701-328-3750 <br /> <br />T-334 P.02/03 F-191 <br /> <br />l/1P"";'.::"!\~~ <br />~'i..;- .,,~i)1 <br />\'),,\. ><'k~. <br />w.... -L"fj'l <br />~":-:~-~~~ <br />(tf~l:":>-" <br /> <br />PREMIUM PAYMENT <br />WORKFORCE SAFETY & INSURANCE <br />EMPLOYER SERVICES <br />SFN 4920 (06/2003) <br /> <br />. . <br />i.aOD.777 ,5033 <br /> <br />BISMARCK NO 58506.5585 <br />T~LEPHONE NUMBER (701) 328.3800 <br />FAX NUMBER (701) 328.3750 <br />TOD NUM6f;R (for the hearinglmpaired onlyl <br />(701) 328.3786 <br />V>NIW.WorkforceSafery.com <br /> <br />, <br />! Qua&.1iol"lt.'? C~II :l$._ Report Inll.d'~ Immcdr;nelY <br /> <br />I NI) Frflud and Safety Hotline I <br />;.800.243.3331 <br />, Report f<llud ana UOsala Well< Condlllen$ I <br /> <br />__ Workforce Safety <br />__~ & Insurance <br />W S I Putting safety to work <br /> <br />MIKE WOLF <br />ND ASSOCIATION OF COUNTIES INC <br />1661 CAPITOL WAY SUITE 100 <br />BISMARCK ND 58501-5600 <br /> <br />Employer Account Number: 1196351 <br />Issued Date: 03/13/2006 <br /> <br />Expiration Date: 03/16/2007 <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 $125 per year. <br /> <br />t7 /J Ii <br />pY~ <br /> <br />Dave Spencer <br />Chief of Employer Services <br /> <br />'~1:Cl$SX :. <br /> <br />R".t, <br /> <br /> <br />. i.C.lq~slfjcation' De~criptiQn <br /> <br />~.Ji "~"~i~'J: ~ik:~., I: ~. <br /> <br />~ <br />i <br />I <br />I <br /> <br />0003Z <br />0010Z <br />3630Z <br />5603Z <br />6042Z <br />7380Z <br />7520Z <br />7700Z <br />7715Z <br />7720Z <br />8747Z <br />! 8805Z <br />. 90022 <br />9007Z <br />9040Z <br />9042Z <br />90622 <br />9071Z <br /> <br />I Florists-Nurseries"Gardening Operations <br />f Poisoning And Spraying <br />I Auto Repair-Body _ Shops-Mech <br />I Consulting Engineers <br />Street And Hwy Const-Maintenance <br />Chauffeurs-School Bus-Ambul <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 Custodians4 Janitorial <br />Hospitals <br />Med Clinics-Physicians-Dentists <br />Schools-Libraries-I nstitutions <br />Restaurants And Loun es <br /> <br />i <br />i <br />, <br />, <br /> <br />J <br />