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<br />. <br />WSI <br /> <br />North Dakota <br />Workforce Safety <br />& Insurance <br />To us, it's personal. <br /> <br />CERTIFICATE OF <br />PREMIUM PAYMENT <br />WORKFORCE SAFETY & INSURANCE <br />EMPLOYER SERVICES <br />SFN 4920 (04/2007) <br /> <br />1600 EAST CENTURY AVENUE, SUITE 1 <br />PO BOX 5585 <br />BISMARCK ND 58506-5585 <br />Telephone 1-800-777-5033 <br />Toll Free Fax 1-888-786-8695 <br />TTY (hearing Impaired) 1-800-366-6888 <br />Fraud and Safety Hotline 1-800-243-3331 <br />www.WorkforceSafety.com <br /> <br />T L STROH ARCHITECTS INC <br />313 NP AVE <br />FARGO ND 58102-4835 <br /> <br />Employer Account Number: 1089473 <br /> <br />Issued Date: OS/22/2008 <br /> <br />Expiration Date: 06/14/2009 <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 ~ 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. <br /> <br />8~ S~'l~ <br /> <br />Barry Schumacher <br />Director of PHS - Operations <br /> <br />Class Classification Description <br />5410A Carpentry <br />5603 Consulting Engineers <br />5603X Optional Coverage <br />8805 Clerical Office Employees <br />