EXHIBIT 10.34 ADVICE OF INSURANCE NUMBER/DATE LAT97-0002A/February 20, 1997 NAMED INSURED OUTSOURCE INTERNATIONAL, INC. et. al. ADDRESS 1144 E. Newport Center Deerfield Beach, FL 33442 Attention: Mike McGowan IN ACCORDANCE WITH YOUR INSTRUCTIONS, WE HAVE ARRANGED INSURANCE ATTACHING FROM March 1, 1997 AND EXPIRING May 1, 1997 TYPE OF COVERAGE WORKERS COMPENSATION & EMPLOYER'S LIABILITY Workers' Compensation: Statutory, all scheduled states Other States Insurance - all Non-monopolistic states Employers Liability: Bodily Injury by Accident - $1,000,000 each accident Bodily Injury by Disease - $1,000,000 each employee Bodily Injury by Disease - $1,000,000 policy limit Terms and Conditions: Deductible - $250,000 per Accident, $500,000 for USL&H Retention - $250,000 per Accident, $500,000 for USL&H Endorsements: Stop Gap - $1,000,000 limit - Monopolistic States Voluntary Compensation Endorsement - USL&H Endorsement Alternate Employer Endorsement - 90 Day Notice of Cancellation 90 Day Notice of Non-Renewal Endorsement INSURANCE COMPANY OF THE STATE OF PA. Pol. #2177940 All other States, Ex. ME, and Monopolistic States Pol. #2177944 - AZ, MD, VA; Pol. #2177945 - CA Pol. #2177946 - ID; Pol. #2177948 - OR NATIONAL UNION UNION FIRE INSURANCE COMPANY OF PA Pol. #2177943 - UT, WI INSURING COMPANY(IES) COVERAGE IS SUBJECT TO ALL TERMS, CONDITIONS AND EXCLUSIONS OF THE POLICY. THE POLICY(IES) ARE BEING PREPARED AND WILL BE FORWARDED TO YOU AS SOON AS POSSIBLE. IMPORTANT IF THERE IS ANY INACCURACY IN THE ABOVE DESCRIPTION OF INSURANCE REQUIRED, PLEASE ADVISE US IMMEDIATELY. /s/ GARY MORRIS ------------------------- Gary Morris Authorized Representative [CENTURY FINANCIAL SERVICES LETTERHEAD] ADVICE OF INSURANCE NUMBER/DATE LAT97-0002/January 1, 1997 NAMED INSURED OUTSOURCE INTERNATIONAL, INC. et. al. ADDRESS 1144 E. Newport Center Deerfield Beach, FL 33442 Attention: Mike McGowan IN ACCORDANCE WITH YOUR INSTRUCTIONS, WE HAVE ARRANGED INSURANCE ATTACHING FROM January 1, 1997 AND EXPIRING March 1, 1997 (policies to be issued with January 1, 1998 expirations) TYPE OF COVERAGE WORKERS COMPENSATION & EMPLOYER'S LIABILITY Workers' Compensation: Statutory, all scheduled states Other States Insurance - all Non-monopolistic states Employers Liability: Bodily Injury by Accident - $1,000,000 each accident Bodily Injury by Disease - $1,000,000 each employee Bodily Injury by Disease - $1,000,000 policy limit Terms and Conditions: Deductible - $250,000 per Accident, $500,000 for USL&H Retention - $250,000 per Accident, $500,000 for USL&H Endorsements: Stop Gap - $1,000,000 limit - Monopolistic States Voluntary Compensation Endorsement - USL&H Endorsement Alternate Employer Endorsement-90 Day Notice of Cancellation 90 Day Notice of Non-Renewal Endorsement INSURANCE COMPANY OF THE STATE OF PA. Pol. #2177940 All other States, Ex. ME, and Monopolistic States Pol. #2177944 - AZ, MD, VA; Pol. #2177945 - CA Pol. #2177946 - ID; Pol. #2177948 - OR NATIONAL UNION UNION FIRE INSURANCE COMPANY OF PA Pol. #2177943 - UT, WI INSURING COMPANY(IES) COVERAGE IS SUBJECT TO ALL TERMS, CONDITIONS AND EXCLUSIONS OF THE POLICY. THE POLICY(IES) ARE BEING PREPARED AND WILL BE FORWARDED TO YOU AS SOON AS POSSIBLE. IMPORTANT IF THERE IS ANY INACCURACY IN THE ABOVE DESCRIPTION OF INSURANCE REQUIRED, PLEASE ADVISE US IMMEDIATELY. /s/ GARY H. MORRIS ------------------------- Gary H. Morris Authorized Representative [CENTURY FINANCIAL SERVICES LETTERHEAD] NOTICE OF PREMIUM DUE [LOGO] Member Companies of This premium is due and payable to the American International Group company 15 days from the date of this bill or 30 days from inceptionof the contract, whichever is later. Additional installments are due and payable on the FOR INSURANCE IN FAVOR OF: indicated due date. If the payment is not received within the time stipulated this policy will be cancelled. OUTSOURCE INTERNATIONAL, INC. 8000 NORTH FEDERAL HIGHWAY ISSUING COMPANY: BOCA RATON FL 33487-0000 INS CO OF THE STATE OF PENN PRODUCER: PRODUCER NUMBER: BILLING DATE: CENTURY FINANCIAL SERVICES 185 N W SPANISH RIVER BLVD. 170 49565 04/10/97 BOCA RATON FL 33481-1088 POLICY NUMBER POLICY PERIOD COMM. RATE PREMIUM DUE - -------------------------------------------------------------------------------- FROM TO WC 217-79-40 01/01/97 01/01/98 0.00000 $2,562,180 - -------------------------------------------------------------------------------- STATE(S) SURCHARGE/TAX 0 $10,589 PAYMENT SCHEDULE: -------------------------------------------------------------- PREPAID DUE & PAYABLE INSTALLMENT DATE DATE AMOUNT DUE 01/01/97 04/26/97 $2,572,729 [LOGO] REMIT TO: AMERICAN INTERNATIONAL COMPANIES AMERICAN INTERNATIONAL COMPANIES P.O. BOX 10642 TOTAL PREMIUM: $2,572,729 NEWARK, N.J. 07193-0842 INSURED'S COPY DATE: 04/11/97 POLICY NUMBER: 217-79-40 UNDERWRITER NAME: ROBERT WINDHAM UNDERWRITER REGION: ATLANTA UNDERWRITER BRANCH: MIAMI UNDERWRITER TELEPHONE: (770) 671-2396 EXT: FILE COPY FSI EPS TRACKING-ID: 0021779409022920 ANY1410D ISSUED BY THE STOCK INSURANCE COMPANY HEREIN CALLED THE COMPANY AGENT NUMBER POLICY NUMBER THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA 13889 49565 RM WC 217-79-40 INCORPORATED UNDER THE LAWS OF PENNSYLVANIA ITEM 1. NAMED INSURED: MAILING ADDRESS IDENTIFICATION NO. OUTSOURCE INTERNATIONAL, INC. [LOGO] Member Companies of 8000 NORTH FEDERAL HIGHWAY American International Group BOCA RATON FL 33487-0000 EXECUTIVE OFFICES: 70 PINE STREET, NEW YORK, N.Y. 10270 I.D.# 917-356254 PRODUCERS NAME & MAILING ADDRESS WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CENTURY FINANCIAL SERVICES INFORMATION PAGE 185 N W SPANISH RIVER BLVD 170 POB 811088 BOCA RATON FL 33481-1088 - -------------------------------------------------------------------------------- INSURED IS CORPORATION PREVIOUS POLICY NUMBER RMWC 2117626 (RENEWAL) - -------------------------------------------------------------------------------- OTHER WORKPLACES NOT SHOWN ABOVE - -------------------------------------------------------------------------------- ITEM 2 POLICY PERIOD 12:01 A.M. STANDARD TIME AT THE INSURED'S MAILING ADDRESS FROM 01/01/97 TO 01/01/98 - -------------------------------------------------------------------------------- ITEM 3 A. WORKERS COMPENSATION INSURANCE: PART ONE OF THE POLICY APPLIES TO WORKERS COMPENSATION LAW OF THE STATES LISTED HERE: AK AL AR CT DC FL GA IA IL IN KY LA MA MI MN MO MS NC NE NH NJ NM NY PA SC SD TN TX ------------------------------------------------------------------------- B. EMPLOYERS LIABILITY INSURANCE: PART TWO OF THE POLICY APPLIES TO THE WORK IN EACH STATE LISTED IN ITEM 3.A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE: BODILY INJURY BY ACCIDENT $1,000,000 EACH ACCIDENT BODILY INJURY BY DISEASE $1,000,000 POLICY LIMIT BODILY INJURY BY DISEASE $1,000,000 EACH EMPLOYEE ------------------------------------------------------------------------- C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO THE STATES, IF ANY, LISTED HERE: ALL STATES EXCEPT AZ CA ID ME MD NV ND OH OR UT VA WA WV WI WY - -------------------------------------------------------------------------------- ITEM 4 THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, CLASSIFICATIONS, RATES AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. ------------------------------------------------------------------------- ESTIMATED TOTAL RATE PER ESTIMATED CLASSIFICATIONS CODE NUMBER REMUNERATION $100 OF RE- PREMIUM [X]ANNUAL [ ]3 YEAR NUMERATION [X]ANNUAL [ ]3 YEAR - -------------------------------------------------------------------------------- SEE ATTACHED SCHEDULES TAXES/ASSESSSMENTS/SURCHARGES $10,569 SEE EXTENSION OF INFORMATION PAGE - -------------------------------------------------------------------------------- EXPENSE CONSTANT (EXCEPT WHERE APPLICABLE BY STATE) $190 MA - -------------------------------------------------------------------------------- MINIMUM PREMIUM $1,725 PA TOTAL ESTIMATED PREMIUM $2,562,160 - -------------------------------------------------------------------------------- Indicated below, interim adjustments of premium shall be made: [ ]Semi-Annually [ ]Quarterly [ ]Monthly DEPOSIT PREMIUM 2,562,160 - -------------------------------------------------------------------------------- ENDORSEMENTS (FORM NUMBER) SEE ATTACHED SCHEDULE - -------------------------------------------------------------------------------- 04/10/97 ATLANTA 07 - ------------------------------------------------- ISSUE DATE PRINT DATE: 04/11/97 ISSUING OFFICE ---------------------------------------- 9967 AUTHORIZED REPRESENTATIVE WC 00 00 01 INSURED'S COPY FORMS SCHEDULE Policy Number: RM WC 217-79-40 Effective Date: 01/01/97 - -------------------------------------------------------------------------------- 53365WC SOLICITATION COMMENTS POL/HLDR 53690WC TEXAS NOTICE WC7738 NOTE POL/HOLDRS ACC PREV SERVS WC000000A TERMS & CONDITIONS WC000101A DEFENSE BASE ACT COVERAGE ENDT WC000106A USL&H WC ACT COVERAGE END. WC000301A ALTERNATE EMPLOYER ENDORSEMENT WC000311A VOL COMP & EL COVERAGE ENDT WC000403 EXPERIENCE RATING MOD FACTOR WC000414 NOTIFICATION OF CHG OWNERSHIP WC53138 LOSS REIMBURSEMENT ENDORSEMENT WC540002 ALASKA SURCHARGE WC540301 AK LIMIT OF LIABILITY ENDT WC540601 NOTICE OF INSTALLMENT OF OPT ENDT LWNAKNOTE AK NOTICE TO EMPLOYEES LWNALASKA AK YOU AND YOUR POLICY 59471WC AR NOTICE TO POLICYHOLDERS WC030601A ARKANSAS AMENDATORY ENDT LWNINPHA AR NOTICE TO POLICYHOLDERS WC060301 CT-APPLICATION OF WC INS WC060303A WC FUNDS COVERAGE ENDT. WC060303B CONNECTICUT WC FUNDS ENDT. WC060501 RETRO PREM SUPPLEM END-CT LWNNPAH NOT POL/HOLDER AMERICAN HO INS WC080601 DC-CANCELLATION WC090402 FL EXPERIENCE RATING MOD ENDT WC100601A GA CANCEL. NONREN CHANGE ENDT WC120601B IL MANDATORY ENDORSEMENT 62958WC IN NOTICE TO POLICYHOLDERS LWNINPOL NOTICE TO POLICYHOLDERS 60713WC KY ADDENDUM TO APPLICATION WC000292 TAX AND ASSESSMENT-KENTUCKY WC170302 PUNITIVE DAMAGES ENDT. WC170601 LOUISIANA AMENDATORY ENDT WC170602A LA COST CONTAINMENT ACT ENDT. WC200301 MA-LIMITS OF LIABILITY WC200302 MA-ASSESSMENT CHARGE WC200303A NOTICE TO POLICYHOLDER ENDT WC200601 MA CANCELLATION ENDORSEMENT WC210303 MI-NOTICE TO POLICYHOLDER WC210601 MI-LAW WC220601A MN CANCELLATION AND RENEWAL EN LWNMNIGA INSURANCE GUARANTY ASSOCIATION WC240301 MO-LIMIT OF LIABILITY WC240403 MO SAFETY CERTIFICATION ENDT. WC240501 RETRO PREM SUPPLEM END-MO WC240601A MISSOURI CANC/NONREW ENDT WC240602A PROPERTY CASUALTY GUARANTY ASS WC63612 NOTICE TO POLICYHOLDER LW0418 (ED. 1-92) INSURED'S COPY FORMS SCHEDULE Policy Number: RM WC 217-79-40 Effective Date: 01/01/97 - -------------------------------------------------------------------------------- WC320301A NC AMENDED COVERAGE ENDT WC260601A NE CANCELLATION ENDORSEMENT WC280601 NH-SOLE REPRESENTATIVE WC280604 NH AMENDATORY ENDORSEMENT WC290301 NJ-PART TWO LIMIT OF LIABILITY LWNNJSIF NEW JERSEY SECOND INJURY FUND LWNNJUFEF NJ UNINSURED EMPLOY FUND SUR WC300302 NM-SAFETY DEVICE EXCLUSION WC300601 CANCELLATION & NONRENEWAL ENDT WC310308 NY-LIMIT OF LIABILITY WC62942 NOT POLICYHOLDER NY CHANGE ASS 59472WC PA NOTICE TO POLICYHOLDERS WC370601 INSPECTION MANUALS-PA WC370602 PA-NOTICE WC370603 PA ACT 86-1986 ENDORSEMENT WC400601 SD-DIRECT ACTION STATUTE WC58978 SD NOTICE TO THE INSURED WC420301D TEXAS AMENDATORY ENDORSEMENT WC420306 MAINTENANCE TAX SURCHARGE END. WC420403 TX-EXP RATING MOD FACTOR LWNTXDED DED NOT/ELEC TO ACC TX WC BENE WC880001 ST OF ME EXCEL 64478(7/96) LARGE RISK RATING PLAN LW0418 (ED. 1-92) INSURED'S COPY WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY National Union Fire Insurance Company of Pittsburgh, Pa. [LOGO] American Home Assurance Company Member Companies of American International Group, Inc. The Insurance Company of EXECUTIVE OFFICES The State of Pennsylvania 70 PINE STREET NEW YORK, N.Y. 10270 Birmingham Fire Insurance Company of Pennsylvania Commerce and Industry Insurance Company Coverage is provided by the Company designated on the Information Page A Stock Insurance Company WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY QUICK REFERENCE BEGINNING ON PAGE Information Page..........................................................i GENERAL SECTION...........................................................1 A. The Policy........................................................1 B. Who Is Insured....................................................1 C. Workers Compensation Law..........................................1 D. State.............................................................1 E. Locations.........................................................1 PART ONE-WORKERS COMPENSATION INSURANCE...................................1 A. How This Insurance Applies........................................1 B. We Will Pay.......................................................1 C. We Will Defend....................................................1 D. We Will Also Pay..................................................1 E. Other Insurance...................................................2 F. Payments You Must Make............................................2 G. Recovery From Others..............................................2 H. Statutory Provisions..............................................2 THESE POLICY PROVISIONS WITH THE INFORMATION PAGE AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THIS POLICY. "INCLUDES COPYRIGHT MATERIAL OF THE NATIONAL COUNCIL ON COMPENSATION INSURANCE, USED WITH ITS PERMISSION. COPYRIGHT 1983 NATIONAL COUNCIL ON COMPENSATION INSURANCE" 39638C(04/92) WC 00 00 00 A (STANDARD) INSURED'S COPY ED 4 O2 QUICK REFERENCE - CONTINUED BEGINNING ON PAGE PART TWO - EMPLOYERS LIABILITY INSURANCE..................................2 A. How this Insurance Applies........................................2 B. We Will Pay.......................................................3 C. Exclusions........................................................3 D. We Will Defend....................................................3 E. We Will Also Pay..................................................4 F. Other Insurance...................................................4 G. Limits of Liability...............................................4 H. Recovery From Others..............................................4 I. Action Against Us.................................................4 PART THREE - OTHER STATES INSURANCE.......................................4 A. How this Insurance Applies........................................4 B. Notice............................................................5 PART FOUR - YOUR DUTIES IF INJURY OCCURS..................................5 PART FIVE - PREMIUM.......................................................5 A. Our Manuals.......................................................5 B. Classifications...................................................5 C. Renumeration......................................................5 D. Premium Payments..................................................5 E. Final Premium.....................................................5 F. Records...........................................................6 G. Audit.............................................................6 PART SIX - CONDITIONS.....................................................6 A. Inspection........................................................6 B. Lont Term Policy..................................................6 C. Transfer of Your Rights and Duties................................6 D. Cancellation......................................................6 E. Sole Representative...............................................6 IMPORTANT: This Quick Reference is NOT part of the Workers Compensation and Employers Liability Policy and does NOT provide coverage. Refer to the Workers Compensation and Employers Liability Policy itself for actual contractual provisions. PLEASE READ THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CAREFULLY INSURED'S COPY ATTACH FORM AND ENDORSEMENTS (IF ANY) HERE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows. GENERAL SECTION A. THE POLICY This policy includes at its effective date the Information Page and all endorsements and schedules listed there. It is a contract of insurance between you (the employer named in Item 1 of the Information Page) and us (the insurer named on the Information Page). The only agreements relating to this insurance are stated in this policy. The terms of this policy may not be changed or waived except by endorsement issued by us to be part of this policy. B. WHO IS INSURED You are insured if you are an employer named in Item 1 of the Information Page. If that employer is a partnership, and if you are one of its partners, you are insured, but only in your capacity as an employer of the partnership's employees. C. WORKERS COMPENSATION LAW Workers Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page. It includes any amendments to that law which are in effect during the policy period. It does not include any federal workers or workmen's compensation law, any federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. D. STATE State means any state of the United States of America, and the District of Columbia. E. LOCATIONS This policy covers all of your workplaces listed in Items 1 or 4 of the Information Page; and it covers all other workplaces in Item 3.A states unless you have other insurance or are self-insured for such workplaces. PART ONE - WORKERS COMPENSATION INSURANCE A. HOW THIS INSURANCE APPLIES This workers compensation insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. Bodily injury by accident must occur during the policy period. 2. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. B. WE WILL PAY We will pay promptly when due the benefits required of you by the workers compensation law. C. WE WILL DEFEND We have the right and duty to defend at our expense any claim, proceeding or suit against you for benefits payable by this insurance. We have the right to investigate and settle these claims, proceedings or suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. D. WE WILL ALSO PAY We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding or suit we defend: 1. reasonable expenses incurred at our request, but not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amount payable under this insurance; WC 00 00 00 A 1 of 7 INSURED'S COPY 3. litigation costs taxed against you; 4. interest on a judgment as required by law until we offer the amount due under this insurance; and 5. expenses we incur. E. OTHER INSURANCE We will not pay more than our share of benefits and costs covered by this insurance and other insurance or self-insurance. Subject to any limits of liability that may apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance will be equal until the loss is paid. F. PAYMENTS YOU MUST MAKE You are responsible for any payments in excess of the benefits regularly provided by the workers compensation law including those required because: 1. of your serious and willful misconduct; 2. you knowingly employ an employee in violation of law; 3. you fail to comply with a health or safety law or regulation; or 4. you discharge, coerce or otherwise discriminate against any employee in violation of the workers compensation law. If we make any payments in excess of the benefits regularly provided by the workers compensation law on your behalf, you will reimburse us promptly. G. RECOVERY FROM OTHERS We have your rights, and the rights of persons entitled to the benefits of this insurance, to recover our payments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. H. STATUTORY PROVISIONS These statements apply where they are required by law. 1. As between an injured worker and us, we have notice of the injury when you have notice. 2. Your default or the bankruptcy or insolvency of you or your estate will not relieve us of our duties under this insurance after an injury occurs. 3. We are directly and primarily liable to any person entitled to the benefits payable by this insurance. Those persons may enforce our duties; so may an agency authorized by law. Enforcement may be against us or against you and us. 4. Jurisdiction over you is jurisdiction over us for purposes of the workers compensation law. We are bound by decisions against you under that law, subject to the provisions of this policy that are not in conflict with that law. 5. This insurance conforms to the parts of the workers compensation law that apply to: a. benefits payable by this insurance or; b. special taxes, payments into security or other special funds, and assessments payable by us under that law. 6. Terms of this insurance that conflict with the workers compensation law are changed by this statement to conform to that law. Nothing in these paragraphs relieves you of your duties under this policy. PART TWO - EMPLOYERS LIABILITY INSURANCE A. HOW THIS INSURANCE APPLIES This employers liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must arise out of and in the course of the injured employee's employment by you. 2. The employment must be necessary or incidental to your work in a state or territory listed in Item 3.A. of the Information Page. 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. If you are sued, the original suit and any related legal actions for damages for bodily injury WC 00 00 00 A 2 of 7 INSURED'S COPY by accident or by disease must be brought in the United States of America, its territories or possessions, or Canada. B. WE WILL PAY We will pay all sums you legally must pay as damages because of bodily injury to your employees, provided the bodily injury is covered by this Employers Liability Insurance. The damages we will pay, where recovery is permitted by law, include damages: 1. for which you are liable to a third party by reason of a claim or suit against you by that third party to recover the damages claimed against such third party as a result of injury to your employee; 2. for care and loss of services; and 3. for consequential bodily injury to a spouse, child, parent, brother or sister of the injured employee; provided that these damages are the direct consequence of bodily injury that arises out of and in the course of the injured employee's employment by you; and 4. because of bodily injury to your employee that arises out of and in the course of employment, claimed against you in a capacity other than as employer. C. EXCLUSIONS This insurance does not cover: 1. liability assumed under a contract. This exclusion does not apply to a warranty that your work will be done in a workmanlike manner; 2. punitive or exemplary damages because of bodily injury to an employee employed in violation of law; 3. bodily injury to an employee while employed in violation of law with your actual knowledge or the actual knowledge of any of your executive officers; 4. any obligation imposed by a workers compensation, occupational disease, unemployment compensation, or disability benefits law, or any similar law; 5. bodily injury intentionally caused or aggravated by you; 6. bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America or Canada who is temporarily outside these countries; 7. damages arising out of coercion, criticism, demotion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimination against or termination of any employee, or any personnel practices, policies, acts or omissions. 8. bodily injury to any person in work subject to the Longshore and Harbor Workers' Compensation Act (33 USC Sections 901-950), the Nonappropriated Fund Instrumentalities Act (5 USC Sections 8171-8173), the Outer Continental Shelf Lands Act (43 USC Sections 1331-1356), the Defense Base Act (42 USC Sections 1651-1654), the Federal Coal Mine Health and Safety Act of 1969 (30 USC Sections 901-942), any other federal workers or workmen's compensation law or other federal occupational disease law, or any amendments to these laws. 9. bodily injury to any person in work subject to the Federal Employers' Liability Act (45 USC Sections 51-60), any other federal laws obligating an employer to pay damages to an employee due to bodily injury arising out of or in the course of employment, or any amendments to those laws. 10. bodily injury to a master or member of the crew of any vessel. 11. fines or penalties imposed for violation of federal or state law. 12. damages payable under the Migrant and Seasonal Agricultural Worker Protection Act (29 USC Sections 1801-1872) and under any other federal law awarding damages for violation of those laws or regulations issued thereunder, and any amendments to those laws. D. WE WILL DEFEND We have the right and duty to defend, at our expense, any claim, proceeding or suit against you for damages payable by this insurance. We have the right to investigate and settle these claims, proceedings and suits. WC 00 00 00 A 3 of 7 INSURED'S COPY We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. We hav no duty to defend or continue defending after we have paid our applicable limit of liability under this insurance. E. WE WILL ALSO PAY We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim proceeding, or suit we defend; 1. reasonable expenses incurred at our request; but not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the limit of our liability under this insurance; 3. litigation costs taxed against you; 4. interest on a judgment as required by law until we offer the amount due under this insurance; and 5. expenses we incur. F. OTHER INSURANCE We will not pay more than our share of damages and costs covered by this insurance and other insurance or self-insurance. Subject to any limits of liability that apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance and self-insurance will be equal until the loss is paid. G. LIMITS OF LIABILITY Our liability to pay for damages is limited. Our limits of liability are shown in Item 3.B. of the Information Page. They apply as explained below. 1. Bodily Injury by Accident. The limit shown for "bodily injury by accident-each accident" is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident. A disease is not bodily injury by accident unless it results directly from bodily injury by accident. 2. Bodily Injury by Disease. The limit shown for "bodily injury by disease-policy limit" is the most we will pay for all damages covered by this insurance and arising out of bodily injury by disease, regardless of the number of employees who sustain bodily injury by disease. The limit shown for "bodily injury by disease each employee" is the most we will pay for all damages because of bodily injury by disease to any one employee. Bodily injury by disease does not include disease that results directly from a bodily injury by accident. 3. We will not pay any claims for damages after we have paid the applicable limit of our liability under this insurance. H. RECOVERY FROM OTHERS We have your rights to recover our payment from anyone liable for an injury covered by this insurance. You will do everything necessary to protect those rights for us and to help us enforce them. I. ACTIONS AGAINST US There will be no right of action against us under this insurance unless: 1. You have complied with all the terms of this policy; and 2. The amount you owe has been determined with our consent or by actual trial and final judgment. This insurance does not give anyone the right to add us as a defendant in an action against you to determine your liability. The bankruptcy or insolvency of you or your estate will not relieve us of our obligations under this Part. PART THREE - OTHER STATES INSURANCE A. HOW THIS INSURANCE APPLIES 1. This other states insurance applies only if one or more states are shown in Item 3.C. of the Information Page. 2. If you begin work in any one of those states after the effective date of this policy and are not insured or are not self-insured for such work, all provisions of the policy will apply as though that state were listed in Item 3.A. of the Information Page. 3. We will reimburse you for the benefits required by the workers compensation law of that state if we are not permitted to pay the benefits directly to persons entitled to them. 4. If you have work on the effective date of this policy in any state not listed in Item 3.A. of the WC 00 00 00 A 4 of 7 INSURED'S COPY Information Page, coverage will not be afforded for that state unless we are notified within thirty days. B. NOTICE Tell us at once if you begin work in any state listed in Item 3.C. of the Information Page. PART FOUR - YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered by this policy. Your other duties are listed here. 1. Provide for immediate medical and other services required by the workers compensation law. 2. Give us or our agent the names and addresses of the injured persons and of witnesses, and other information we may need. 3. Promptly give us all notices, demands and legal papers related to the injury, claim, proceeding or suit. 4. Cooperate with us and assist us, as we may request, in the investigation, settlement or defense of any claim, proceeding or suit. 5. Do nothing after an injury occurs that would interfere with our right to recover from others. 6. Do not voluntarily make payments, assume obligations or incur expenses, except at your own cost. PART FIVE - PREMIUM A. OUR MANUALS All premium for this policy will be determined by our manuals of rules, rates, rating plans and classifications. We may change our manuals and apply the changes to this policy if authorized by law or a governmental agency regulating this insurance. B. CLASSIFICATIONS Item 4 of the Information Page shows the rate and premium basis for certain business or work classifications. These classifications were assigned based on an estimate of the exposures you would have during the policy period. If your actual exposures are not properly described by those classifications, we will assign proper classifications, rates and premium basis by endorsement to this policy. C. REMUNERATION Premium for each work classification is determined by multiplying a rate times a premium basis. Remuneration is the most common premium basis. This premium basis includes payroll and all other remuneration paid or payable during the policy period for the services of: 1. All your officers and employees engaged in work covered by this policy; and 2. All other persons engaged in work that could make us liable under Part One (Workers Compensation Insurance) of this policy. If you do not have payroll records for these persons, the contract price for their services and materials may be used as the premium basis. This paragraph 2 will not apply if you give us proof that the employers of these persons lawfully secured their workers compensation obligations. D. PREMIUM PAYMENTS You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. E. FINAL PREMIUM The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the balance. If it is less, we will refund the balance to you. The final premium will not be less than the highest minimum premium for the classifications covered by this policy. If this policy is canceled, final premium will be determined in the following way unless our manuals provide otherwise. 1. If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rate share of the minimum premium. 2. If you cancel, final premium will be more than pro rata; it will be based on the time this policy was in force, and increased by our short rate WC 00 00 00 A 5 of 7 INSURED'S COPY cancellation table and procedure. Final premium will not be less than the minimum premium. F. RECORDS You will keep records of information needed to compute premium. You will provide us with copie of those records when we ask for them. G. AUDIT You will let us examine and audit all your records that relate to this policy. These records include ledgers, journals, registers, vouchers, contracts, tax reports, payroll and disbursement records, and programs for storing and retrieving data. We may conduct the audits during regular business hours during the policy period and within three years after the policy period ends. Information developed by audit will be used to determine final premium. Insurance rate service organizations have the same rights we have under this provision. PART SIX - CONDITIONS A. INSPECTION We have the right, but are not obliged to inspect your workplaces at any time. Our inspections are not safety inspections. They relate only to the insurability of the workplaces and the premiums to be charged. We may give you reports on the conditions we find. We may also recommend changes. While they may help reduce losses, we do not undertake to perform the duty of any person to provide for the health or safety of your employees or the public. We do not warrant that your workplaces are safe or healthful or that they comply with laws, regulations, codes or standards. Insurance rate service organizations have the same rights we have under this provision. B. LONG TERM POLICY If the policy period is longer than one year and sixteen days, all provisions of this policy will apply as though a new policy were issued on each annual anniversary that this policy is in force. C. TRANSFER OF YOUR RIGHTS AND DUTIES Your rights or duties under this policy may not be transferred without our written consent. If you die and we receive notice within thirty days after your death, we will cover your legal representative as insured. D. CANCELLATION 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancellation is to take effect. 2. We may cancel this policy. We must mail or deliver to you not less than ten days advance written notice stating when the cancellation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 3. The policy period will end on the day and hour stated in the cancellation notice. 4. Any of these provisions that conflicts with a law that controls the cancellation of the insurance in this policy is changed by this statement to comply with that law. E. SOLE REPRESENTATIVE The insured first named in Item 1 of the Information Page will act on behalf of all insureds to change this policy, receive return premium, and give or receive notice of cancellation. WC 00 00 00 A 6 of 7 INSURED'S COPY In WITNESS WHEREOF, the company has caused this policy unless countersigned by a duly authorized representative of the company. /s/ WILLIAM D. SMITH /s/ [ILLEGIBLE] -------------------- --------------- William D. Smith President President The Insurance Company National Union Fire of The State of Pennsylvania Insurance Company of Birmingham Fire Insurance Pittsburgh, PA Company of Pennsylvania /s/ WALTER L. MOONEY /s/ [ILLEGIBLE] -------------------- --------------- Walter L. Mooney President President Commerce and Industry American Home Insurance Company Assurance Company /s/ ELIZABETH M. TUCK --------------------- Elizabeth M. Tuck Secretary National Union Fire Insurance Company of Pittsburgh, PA American Home Assurance Company The Insurance Company of The State of Pennsylvania Birmingham Fire Insurance Company of Pennsylvania Commerce and Industry Insurance Company WC 00 00 00 A 7 of 7 INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 ALASKA ------------------------------- - --------------- --------------- STATE EMPLOYER/UNEMPLOYER ID POLICY PREFIX & NO. SCHEDULE ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. SYNADYNE I JOBSITE ONLY ANCHORAGE, AK 99501 CLERICAL OFFICE EMPLOYEES NOC 8810 781,737 0.58 4,534 UNMODIFIED PREMIUM 4,534 INCREASED LIMITS-EMPLOYER LIABILITY 3.3% 9812 150 TOTAL UNMODIFIED PREMIUM 4,684 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 - 984 SCHEDULE MODIFICATION 25% 9887 - 925 MODIFIED STANDARD PREMIUM 2,775 LOSS REIMBURSEMENT $250,000 9862 - 1,318 UNDISCOUNTED PREMIUM 1,457 TOTAL ESTIMATED ANNUAL PREMIUM 1,457 TOTAL DUE 1,457 WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 ALABAMA ------------------------------- - --------------- --------------- STATE EMPLOYER/UNEMPLOYER ID POLICY PREFIX & NO. SCHEDULE ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. SYNADYNE I JOBSITE ONLY BIRMINGHAM, AL 35201 STORE: RETAIL NOC 8017 17,200 2.37 408 CLERICAL OFFICE EMPLOYEES NOC 8810 813,800 0.37 3,011 UNMODIFIED PREMIUM 3,419 INCREASED LIMITS-EMPLOYER LIABILITY 3.3% 9812 113 LOSS REIMBURSEMENT $250,000 9962 - 1,961 TOTAL UNMODIFIED PREMIUM 1,571 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 - 330 SCHEDULE MODIFICATION 15% 9887 - 186 MODIFIED STANDARD PREMIUM 1,055 DISCOUNTED PREMIUM 1,055 TOTAL ESTIMATED ANNUAL PREMIUM 1,055 TOTAL DUE 1,055 WC7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 ARKANSAS ------------------------------- - --------------- --------------- STATE EMPLOYER/UNEMPLOYER ID POLICY PREFIX & NO. SCHEDULE ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. OUTSOURCE INTERNATIONAL, INC. NEED ADDRESS ENTIRE STATE, AR 99999 FEED MFG. 2014 24,500 7.37 1,806 CREAMERY OR DAIRY & ROUTE 2070 1,200 3.74 45 SUPERVISORS, DRIVERS PACKAGING HOUSE - ALL OPERATIONS NPD 2089 50 7.59 4 BOTTLING NOC & ROUTE SUPERVISORS, 2157 18,700 3.76 703 DRIVERS CLOTHING MFG. 2501 4,700 2.97 140 LAUNDRY NOC & ROUTE SUPERVISORS, 2585 4,200 4.56 192 SALESMEN, DRIVERS PIPE OR TUBE MFG. - IRON OR STEEL - NOT 3028 1,000 5.15 52 CAST IRON - & DRIVERS SHEET METAL WORK - SHOP 3066 700 4.54 32 METAL STAMPING MFG 3400 4,100 4.68 192 APPLICABLE TO MASS PRODUCTION MANUFACTURING OF STAMPED METAL ARTICLES INCLUDING, BUT NOT LIMITED TO, LICENSE PLATES, TAGS, TOYS, PIE PLATES, BUCKETS AND WASTE BASKETS. MILLWRIGHT WORK NOC & DRIVERS 3724 600 7.16 43 AUTOMOBILE, BUS, TRUCK, OR TRAILER 3824 1,100 7.85 86 BODY MFG: NOC CONCRETE PRODUCTS MFG. & DRIVERS 4034 2,100 9.46 199 BOOKBINDING 4307 150 2.80 4 BIOGRAPH RECORD MFG 4431 5,200 2.78 145 WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 ARKANSAS ------------------------------- - --------------- --------------- STATE EMPLOYER/UNEMPLOYER ID POLICY PREFIX & NO. SCHEDULE ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. PLASTICS MFG: FABRICATED PRODUCTS NOC 4452 300 2.70 8 RENDERING WORKS NOC & DRIVERS 4665 100 13.12 13 PHOTOGRAPHIC SUPPLIES MFG 4923 100 1.57 2 FURNITURE OR FIXTURES INSTALLATION - 5146 1,100 7.90 87 PORTABLE - NOC PLUMBING NOC & DRIVERS 5183 1,500 5.36 80 ELECTRICAL WIRING - WITHIN BUILDINGS 5190 1,000 4.30 43 & DRIVERS. VENDING OR COIN OPERATED 5192 60 4.85 3 MACHINES-INSTALLATION SERVICE OR REPAIR-INCLUDING SALESMEN DRIVERS CONCRETE CONSTRUCTION NOC 5213 4,500 13.24 596 TILE, STONE, MOSAIC OR TERRAZZO WORK - 5348 300 4.33 13 INSIDE. SHEET ROCK INSTALLATION - WITHIN 5445 140 9.38 13 BUILDINGS & DRIVERS STREET OR ROAD CONSTRUCTION OR 5506 600 6.46 39 RECONSTRUCTION & DRIVERS FILLING OR GRADING TUNNELING BRIDGE OR CULVERT BUILDING QUARRYING STONE CRUSHING TO BE SEPARATELY RATED FILLING OR GRADING TUNNELING BRIDGE OR CULVERT BUILDING QUARRYING STONE CRUSHING TO BE SEPARATELY RATED CLEANER - DEBRIS REMOVAL 5610 82,300 7.45 6.131 CARPENTRY - DETACHED ONE OR TWO FAMILY 5645 300 12.75 38 DWELLINGS CARPENTRY-DWELLINGS-THREE STORIES 5651 3,300 12.98 428 OR LESS ___GAS WELL: DRILLING OR REDRILLING 6235 3,000 16.87 506 WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 ARKANSAS ------------------------------- - --------------- --------------- STATE EMPLOYER/UNEMPLOYER ID POLICY PREFIX & NO. SCHEDULE ------------------------------- INTRA/INDEPENDENT STATE RISKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. & DRIVERS FOOD SUNDRIES MFG. N O C - NO CEREAL 6504 1,600 4.34 69 MILLING TRUCKING - LOCAL HAULING ONLY & DRIVERS 7228 700 13.43 94 DRIVERS, CHAUFFEURS AND THEIR HELPERS 7380 10,000 5.51 551 NOC-COMMERCIAL ALE OR BEER DEALER - WHOLESALE - & 7390 13,400 3.59 481 DRIVERS STORE: GROCERY - RETAIL 8006 1,500 3.79 57 STORE: HARDWARE 8010 1,500 1.57 24 ___CK PRINTING - COPYING OR DUPLICATING 8015 150 1.57 2 ___SCE - ALL EMPLOYEES & CLERICAL, SALESPERSONS, DRIVERS STORE: RETAIL NOC 8017 1,200 1.57 19 STORE RISKS - WHOLESALE OR COMBINED 8018 20,700 4.46 923 WHOLESALE AND RETAIL - N.O.C. DEPARTMENT STORES--RETAIL 8039 150 2.02 3 FURNITURE STORES--WHOLESALE OR RETAIL - 8044 5,900 3.59 212 & DRIVERS RUBBER STOCK DEALER - USED - AND 8264 21,400 7.12 1,524 DRIVERS NPD STORAGE WAREHOUSE - FURNITURE - & 8293 4,700 9.23 434 DRIVERS AUTOMOBILE SERVICE OR REPAIR CENTER 8380 4,300 3.47 149 AND DRIVERS METAL SCRAP DEALER & DRIVERS NPD 8500 14,200 9.57 1,359 SALESPERSONS, COLLECTORS OR MESSENGERS - 8742 15,600 0.62 97 ___IDE WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 ARKANSAS ------------------------------- - --------------- --------------- STATE EMPLOYER/UNEMPLOYER ID POLICY PREFIX & NO. SCHEDULE ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. LETTER SERVICE SHOP & CLERICAL NPD 8800 700 2.71 19 CLERICAL OFFICE EMPLOYEES NOC 8810 61,200 0.36 220 BUILDINGS-OPERATION BY CONTRACTORS 9014 1,000 4.46 45 BUILDINGS NOC-OPERATION BY OWNER OR 9015 700 5.04 35 LESSEE AMUSEMENT PARK OR EXHIBITION 9016 600 3.44 21 OPERATION & DRIVERS HOSPITAL: ALL OTHER EMPLOYEES 9040 100 4.09 4 HOTEL - ALL EMPLOYEES & SALESPERSON & 9052 10,000 4.13 413 DRIVERS RESTAURANT NOC 9082 700 2.49 17 CARPET INSTALLATION 9521 30,400 5.39 1,639 UNMODIFIED PREMIUM 20,054 INCREASED LIMITS-EMPLOYER LIABILITY 3.3% 9812 662 TOTAL UNMODIFIED PREMIUM 20,716 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 - 4,350 MODIFIED STANDARD PREMIUM 16,366 LOSS REIMBURSEMENT $250,000 9862 - 10,887 UNDISCOUNTED PREMIUM 5,479 TOTAL ESTIMATED ANNUAL PREMIUM 5,479 TOTAL DUE 5,479 WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 CONNECTICUT ------------------------------- - --------------- --------------- STATE EMPLOYER/UNEMPLOYER ID POLICY PREFIX & NO. SCHEDULE ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. LABOR WORLD OF AMERICA, INC. 101 AIRPORT ROAD HARTFORD, CT 06114 FARM: NURSERY EMPLOYEES & DRIVERS 0005 131,700 5.54 7,296 INCLUDES INCIDENTAL LANDSCAPE GARDENING LANDSCAPE GARDENING & DRIVERS 0042 5,200 9.37 487 CODES 0042 AND 9102 PARK NOC MAY BE ASSIGNED TO THE SAME RISK. THE PAYROLL OF AN INDIVIDUAL EMPLOYEE MAY BE DIVIDED AND ALLOCATED BETWEEN CODES 0042 AND 9102 PROVIDED THAT THE ENTRIES ON THE ORIGINAL RECORDS OF THE INSURED DISCLOSE ALLOCATION OF EACH INDIVIDUAL'S._______ AN ESTIMATE OR PERCENTAGE ALLOCATION OF PAYROLL IS NOT PERMITTED. CLOTHING MFG. 2501 4,600 5.34 246 LAUNDRY NOC & ROUTE SUPERVISORS, 2585 22,300 6.29 1,403 SALESMEN, DRIVERS RATTAN, WILLOW OR TWISTED FIBER PRODUCTS 2913 3,400 6.53 222 MFG HEAT TREATING-METAL-N P D 3307 700 6.52 46 WELDING OR CUTTING NOC & DRIVERS 3365 3,100 13.74 426 COMPUTING, RECORDING OR OFFICE MACHINE 3574 478,503 2.53 12,106 MFG NOC PRECISION MACHINED PARTS MFG NOC NPD 3629 12,500 2.72 340 ELECTRICAL CORD SET, RADIO OR IGNATION 3681 4,800 2.78 133 HARNESS ASSEMBLY PLASTICS MFG: MOLDED PRODUCTS NOC 4484 9,000 5.50 495 ___NER - DEBRIS REMOVAL 5610 15,500 8.54 1,324 WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 CONNECTICUT ------------------------------- - --------------- --------------- STATE EMPLOYER/UNEMPLOYER ID POLICY PREFIX & NO. SCHEDULE ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. DRIVERS, CHAUFFEURS AND THEIR HELPERS 7380 300 10.23 31 NON-COMMERCIAL STORE: HARDWARE 8010 3,000 2.98 89 STORE: RETAIL NOC 8017 2,100 2.64 55 STORE-MEAT, GROCERY AND PROVISION 8033 2,300 4.36 100 COMBINED RETAIL NOC SEED MERCHANT 8102 12,400 2.93 363 MACHINERY DEALER NOC - STORE OR YARD - 8107 2,200 6.50 143 & DRIVERS BUILDING MATERIAL DEALER - NEW MATERIALS 8232 14,300 9.58 1,370 ALL OTHER EMPLOYEES & YARD, WAREHOUSE, DRIVERS RUBBER STOCK DEALER - USED - AND 8264 14,200 13.69 1,944 DRIVERS NPD STORAGE WAREHOUSE NOC 8292 300 12.70 38 STORAGE WAREHOUSE - FURNITURE - & 8293 2,700 16.15 436 DRIVERS ARCHITECT OR ENGINEER - CONSULTING NPD 8601 60,700 1.45 880 CLERICAL OFFICE EMPLOYEES NOC 8810 913,600 0.42 3,837 BUILDINGS-OPERATION BY CONTRACTORS 9014 29,200 4.44 1.296 BUILDINGS NOC-OPERATION BY OWNER OR 9015 53,600 6.94 3,720 LESSEE WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 CONNECTICUT ------------------------------- - --------------- --------------- STATE EMPLOYER/UNEMPLOYER ID POLICY PREFIX & NO. SCHEDULE ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. UNMODIFIED PREMIUM 38,826 INCREASED LIMITS-EMPLOYER LIABILITY 3.3% 9812 1,281 TOTAL UNMODIFIED PREMIUM 40,107 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 - 8,422 MODIFIED STANDARD PREMIUM 31,685 LOSS REIMBURSEMENT $250,000 9862 - 4,663 UNDISCOUNTED PREMIUM 31,685 TOTAL ESTIMATED ANNUAL PREMIUM 27,022 ASSESSMENT FUND .8% 0088 253 SECOND INJURY FUND SURCHARGE 13.5% 0088 4,277 TOTAL DUE 31,552 WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 DISTRICT OF COLUMBIA ------------------------------- - --------------- --------------- STATE EMPLOYER/UNEMPLOYER ID POLICY PREFIX & NO. SCHEDULE ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. OUTSOURCE INTERNATIONAL, INC. JOBSITE ONLY WASHINGTON, DC 20315 CLERICAL OFFICE EMPLOYEES NOC 8810 571,300 0.30 1,714 UNMODIFIED PREMIUM 1,714 INCREASED LIMITS-EMPLOYER LIABILITY 3.3% 9812 57 TOTAL UNMODIFIED PREMIUM 1,771 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 - 372 MODIFIED STANDARD PREMIUM 1,399 LOSS REIMBURSEMENT $250,000 9862 - 704 UNDISCOUNTED PREMIUM 695 TOTAL ESTIMATED ANNUAL PREMIUM 695 TOTAL DUE 695 WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 GEORGIA ------------------------------- - --------------- --------------- STATE EMPLOYER/UNEMPLOYER ID POLICY PREFIX & NO. SCHEDULE ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. LEATHER GOODS MFG 2268 4,300 6.19 266 PLANING OR MOLDING MILL 2731 2,700 9.20 248 CARPENTRY SHOP ONLY AND DRIVERS 2802 1,000 14.87 149 CABINET WORKS - WITH POWER MACHINERY 2812 800 9.17 73 FURNITURE ASSEMBLING-WOOD-FROM 2881 44,600 7.95 3,546 MANUFACTURED PARTS FURNITURE MFG - WOOD - NOC 2883 1,500 12.41 186 SIGN MFG - METAL 3064 100 8.50 9 SHEET METAL WORK - SHOP 3066 20,100 12.50 2,513 ___TON OR FASTENER MFG-METAL 3131 700 3.51 25 BRASS OR COPPER GOODS MFG 3315 800 5.76 46 WELDING OR CUTTING NOC & DRIVERS 3365 6,750 20.84 1,407 METAL STAMPING MFG 3400 9,900 11.23 1,112 APPLICABLE TO MASS PRODUCTION MANUFACTURING OF STAMPED METAL ARTICLES INCLUDING, BUT NOT LIMITED TO, LICENSE PLATES, TAGS, TOYS, PIE PLATES, BUCKETS AND WASTE BASKETS. COMPUTING, RECORDING OR OFFICE MACHINE 3574 4,000 1.88 75 MFG NOC PUMP MFG 3612 10,100 4.07 411 MACHINE SHOP NOC 3632 352,500 6.48 22,842 RADIO APPARATUS MFG OR ASSEMBLY NOC 3681 16,500 3.48 574 CONCRETE PRODUCTS MFG & DRIVERS 4034 44,900 18.17 8,158 PAPER MFG 4239 15,200 2.88 438 BOX MFG - FOLDING PAPER - NOC 4243 119,100 6.50 7,742 WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 FLORIDA ------------------------------- - --------------- --------------- STATE EMPLOYER/UNEMPLOYER ID POLICY PREFIX & NO. SCHEDULE ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. OUTSOURCE INTERNATIONAL, INC. 8000 NORTH FEDERAL HIGHWAY BOCA RATON, FL 33487 CLERICAL OFFICE EMPLOYEES NOC 8810 9,063,300 0.56 50,754 SYNADYNE I 4601 NORTHWEST 17TH WAY FT. LAUDERDALE, FL 33309 CLERICAL OFFICE EMPLOYEES NOC 8810 18,667,300 0.56 104,537 COLLEGE: PROFESSIONAL EMPLOYEES & 8868 120,465 1.06 1,277 CLERICAL LABOR WORLD OF AMERICA, INC. 6301 N.W. 5TH WAY FT. LAUDERDALE, FL 33309 FARM: NURSERY EMPLOYEES & DRIVERS 0005 2,300 12.19 280 INCLUDES INCIDENTAL LANDSCAPE GARDENING FARMS: POTATO & DRIVERS 0008 900 8.07 73 FARM: FLORIST & DRIVERS 0035 21,000 4.46 937 LANDSCAPE GARDENING & DRIVERS 0042 28,500 15.43 4,398 GROVE CARETAKING OPERATIONS-BY 0050 6,400 15.57 996 CONTRACTORS-INCLUDING DRIVERS IRRIGATION WORKS OPERATION 0251 3,000 8.55 257 ___NSERVANT 0913 6 405.00 2,430 DOMESTIC SERVICE CONTRACTOR - INSIDE 0917 100 11.26 11 ___E MFG 1701 15,000 5.20 780 WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 FLORIDA ------------------------------- - --------------- --------------- STATE EMPLOYER/UNEMPLOYER ID POLICY PREFIX & NO. SCHEDULE ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. STONE CRUSHING & DRIVERS NPD 1710D 1,200 14.90 179 CREAMERY OR DAIRY & ROUTE 2070 200 8.24 16 SUPERVISORS, DRIVERS CLOTHING MFG. 2501 2,300 4.54 104 LAUNDRY NOC & ROUTE SUPERVISORS, 2585 200 10.71 21 SALESMEN, DRIVERS CLEANING OR DYEING & ROUTE SUPERVISORS, 2586 900 4.97 45 SALESMEN, DRIVERS BOX, BOX SHOOK OR PALLET MFG 2759 9,600 9.15 878 WOODEN FURNITURE ASSEMBLING-WOOD-FROM 2881 13,200 6.01 793 MANUFACTURED PARTS SHEET METAL WORK - SHOP 3066 5,400 11.30 610 METAL EQUIPMENT MFG 3076 46,600 7.74 3,607 TOOL MFG - NOT DROP OR MACHINE FORGED - 3113 210,000 4.11 8,631 NOC BUTTON OR FASTENER MFG-METAL 3131 1,900 4.23 80 ELECTRICAL APPARATUS MFG NOC 3179 50,200 4.48 2,249 ELECTRIC OR GAS LIGHTING FIXTURES MFG. 3180 156,700 6.91 10,828 WELDING OR CUTTING NOC & DRIVERS 3365 15,000 32,28 4,842 COMPUTING, RECORDING OR OFFICE MACHINE 3574 1,950,500 0.93 18,140 FG NOC BOILERMAKING 3620 1,800 12.78 230 MACHINE SHOP NOC 3632 105,000 7.45 7,823 AUTOMATIC SPRINKLER HEAD MFG. 3634 1,050 3.78 40 ___FG OR GRINDING-N P D 3635 1,500 4.99 75 WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 FLORIDA ------------------------------- - --------------- --------------- STATE EMPLOYER/UNEMPLOYER ID POLICY PREFIX & NO. SCHEDULE ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. RADIO APPARATUS MFG OR ASSEMBLY NOC 3681 356,400 2.48 8,839 ELECTRICAL APPARATUS INSTALLATION OR 3724 15,500 15.95 2,472 REPAIR & DRIVERS CONCRETE PRODUCTS MFG & DRIVERS 4034 300 14.24 43 POTTERY MFG: CHINA OR TABLEWARE 4053 5,100 9.08 463 LIGHT BULB MFG 4112 9,200 2.63 242 INCLUDES INCANDESCENT FLOURESCENT, X-RAY, TELEVISION OR CATHODE TUBE MFG. PRINTING 4299 138,100 4.81 6,643 ENGRAVING 4352 188,600 2.62 4,941 BONE OR IVORY GOODS MFG 4452 21,000 5.30 1,113 PLASTICS MFG: MOLDED PRODUCTS NOC 4484 577,000 7.02 40,505 IRON ERECTION NON-STRUCTURAL 5102 400 17.82 71 - - INTERIOR FURNITURE OR FIXTURES INSTALLATION - 5146 1,600 16.50 264 PORTABLE - NOC PLUMBING NOC & DRIVERS 5183 1,500 13.50 203 ELECTRICAL WIRING - WITHIN BUILDINGS 5190 131,700 11.51 15,159 & DRIVERS. OFFICE MACHINE OR APPLIANCE 5191 334,900 2.22 7,435 INSTALLATION, INSPECTION, ADJUSTMENT OR REPAIR CONCRETE WORK-INCIDENTAL TO THE 5215 16,200 20.21 3,274 CONSTRUCTION OF PRIVATE RESIDENCE CONCRETE OR CEMENT WORK - FLOORS, 5221 96,400 16.35 15,761 DRIVEWAYS, YARDS OR SIDEWALKS - & ___RS WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 FLORIDA ------------------------------- - --------------- --------------- STATE EMPLOYER/UNEMPLOYER ID POLICY PREFIX & NO. SCHEDULE ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. SWIMMING POOL CONSTRUCTION AND MAINTE- 5223 100 12.91 13 ANCE FENCE ERECTION - WOOD NOC 5403 15,800 29.77 4,704 CARPENTRY - INSTALLATION OF FINISHED 5437 15,400 21.45 3,303 WOODEN FLOORING PAINTING-OR PAPER HANGING NOC & SHOP 5474 47,100 28.47 13,409 OPERATIONS, DRIVERS PAPER HANGING & DRIVERS 5491 2,000 13.08 262 STREET OR ROAD CONSTRUCTION & DRIVERS 5507 1,500 15.77 237 STREET OR ROAD MAINTENANCE OR 5509 400 9.50 38 ___TIFICATION-NO CONSTRUCTION-INCLUDING ___RS HEATING AND AIR CONDITION DUCT 5536 900 18.56 167 WORKSHOP AND OUTSIDE-& DRIVERS METAL CEILING OR WALL COVERING 5538 31,800 18.56 5,902 INSTALLATION & SHOP, DRIVERS CLEANER - DEBRIS REMOVAL 5610 330,100 20.34 67,142 & CONSTRUCTION OR ERECTION CONTRACTOR. CARPENTRY - DETACHED ONE OR TWO FAMILY 5645 43,683 35.27 15,407 DWELLINGS GRADING OF LAND NOC & DRIVERS 6217 700 14.88 104 FOOD SUNDRIES MFG.N O C - NO CEREAL 6504 46,400 5.92 2,747 MILLING TRUCKING: 7231 244,700 9.58 23,442 MAIL, PARCEL OR PACKAGE DELIVERY-ALL EMPLOYEES & DRIVERS DRIVERS, CHAUFFEURS AND THEIR HELPERS 7380 62,300 9.73 6,062 ___OC-COMMERCIAL ___MOBILE RENTAL CO: ALL OTHER 7382 310,700 11.62 36,103 WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 FLORIDA ------------------------------- - --------------- --------------- STATE EMPLOYER/UNEMPLOYER ID POLICY PREFIX & NO. SCHEDULE ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. EMPLOYEES & DRIVERS ALE OR BEER DEALER - WHOLESALE - & 7390 400 8.36 33 DRIVERS TELEPHONE COMPANY - ALL OTHER EMPLOYEES 7600 8,300 4.35 361 INCLUDING DRIVERS. BURGLAR ALARM INSTALLATION OR REPAIR & 7605 222,100 6.29 13,970 DRIVERS STORE: COFFEE, TEA OR SPICE - RETAIL 8006 54,500 9.47 5,161 STORE: SHOE - RETAIL 8008 70,200 2.28 1,601 STORE: HARDWARE 8010 3,100 3.44 107 STORE: JEWELRY 8013 202,100 1.46 2,951 QUICK PRINTING - COPYING OR DUPLICATING 8015 151,400 3.30 4,996 SERVICE - ALL EMPLOYEES & CLERICAL, SALESPERSONS, DRIVERS STORE: RETAIL NOC 8017 2,691,000 3.30 88,803 STORE GROCERY WHOLESALE 8018 1,242,700 6.98 86,740 STORE: SHOE WHOLESALE 8032 36,900 3.45 1,273 FURNITURE STORES -- WHOLESALE OR RETAIL - 8044 90,900 6.10 5,545 & DRIVERS METAL MERCHANT & DRIVERS 8106 94,400 9.18 8,666 APPLIES TO DEALERS OF IRON, STEEL OR NONFERROUS METAL. MACHINERY DEALER NOC - STORE OR YARD - 8107 200 9.30 19 & DRIVERS VEGETABLE PACKAGING & SALESMEN, DRIVERS 8209 500 7.26 36 BUILDING MATERIAL DEALER - NEW MATERIALS 8232 24,000 11.31 2,714 ONLY: ALL OTHER EMPLOYEES & YARD, WAREHOUSE DRIVERS WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 FLORIDA ------------------------------- - --------------- --------------- STATE EMPLOYER/UNEMPLOYER ID POLICY PREFIX & NO. SCHEDULE ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. RUBBER STOCK DEALER - USED - AND 8264 166,100 12.69 21,078 DRIVERS NPD STORAGE WAREHOUSE NOC 8292 113,900 9.57 10,900 STORAGE WAREHOUSE - FURNITURE - & 8293 2,200 18.68 411 DRIVERS AUTOMOBILE SERVICE OR REPAIR CENTER 8380 506,700 6.69 33,898 AND DRIVERS AUTOMOBILE STORAGE GARAGE OR PARKING 8392 1,300 5.47 71 STATION & DRIVERS AUTOMOBILE BUMPER REPAIR 8393 535,821 5.79 31,024 BONDED WAREHOUSING - ALL EMPLOYEES 8710 100 3.42 3 & CLERICAL REAL ESTATE APPRAISAL COMPANY-OUTSIDE 8721 193,800 1.16 2,248 EMPLOYEES SALESPERSONS, COLLECTORS OR MESSENGERS - 8742 4,044,700 1.16 46,919 OUTSIDE AUTOMOBILE SALESMEN 8748 830,500 1.61 13,371 COMPUTER SYSTEM DESIGNERS OR 8803 1,690,100 0.34 5,746 PROGRAMMERS: TRAVELING CLERICAL OFFICE EMPLOYEES NOC 8810 37,708,600 0.56 211,168 LAW OFFICE-ALL EMPLOYEES & CLERICAL 8820 2,201,300 0.45 9,906 MESSENGERS, DRIVERS NPD PHYSICIAN & CLERICAL 8832 3,722,600 0.76 28,292 HOSPITAL - PROFESSIONAL EMPLOYEES 8833 2,031,900 2.42 49,172 COLLEGE: PROFESSIONAL EMPLOYEES & 8868 2,579,700 1.06 27,345 CLERICAL TELEPHONE OR TELEGRAPH CO: OFFICE OR 8901 100 0.28 0 WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 FLORIDA ------------------------------- - --------------- --------------- STATE EMPLOYER/UNEMPLOYER ID POLICY PREFIX & NO. SCHEDULE ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. EXCHANGE EMPLOYEES & CLERICAL JANITORIAL SERVICE BY CONTRACTOR--NO 9000 333,800 8.17 27,271 WINDOW CLEANING BUILDINGS-OPERATION BY CONTRACTORS 9014 99,800 7.69 7,675 BUILDINGS NOC-OPERATION BY OWNER OR 9015 384,700 9.00 34,623 LESSEE AMUSEMENT PARK OR EXHIBITION 9016 10,100 7.55 763 OPERATION & DRIVERS HOSPITAL: ALL OTHER EMPLOYEES 9040 125,000 8.37 10,463 HOTEL - ALL EMPLOYEES & CLERICAL 9052 99,900 6.92 6,913 HOTEL: RESTAURANT EMPLOYEES 9058 203,100 5.58 11,333 CLUB - COUNTRY, GOLF, FISHING OR YACHT - 9060 51,800 5.09 2,637 & CLERICAL CLUB NOC & CLERICAL 9061 1,100 4.65 51 RESTAURANT NOC 9082 150 5.64 8 ROLLER SKATING RINK OPERATION 9093 1,200 2.51 30 COLLEGES OR SCHOOLS ALL OTHER EMPLOYEES 9101 90,900 7.16 6,508 LAWN MAINTENANCE-COMMERCIAL OR 9102 33,300 8.02 2,671 DOMESTIC & DRIVERS SEWER CLEANING & DRIVERS 9402 100 11.86 12 HOUSEHOLD APPLIANCES - ELECTRICAL - 9519 83,900 5.77 4,841 INSTALLATION, SERVICE OR REPAIR - & DRIVERS. CARPET INSTALLATION 9521 1,000 13.97 140 WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 FLORIDA ------------------------------- - --------------- --------------- STATE EMPLOYER/UNEMPLOYER ID POLICY PREFIX & NO. SCHEDULE ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. UNMODIFIED PREMIUM 1,342,858 INCREASED LIMITS-EMPLOYER LIABILITY 3.3% 9812 44,314 TOTAL UNMODIFIED PREMIUM 1,387,172 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 - 291,306 MODIFIED STANDARD PREMIUM 1,095,866 LOSS REIMBURSEMENT $250,000 9862 - 165,298 UNDISCOUNTED PREMIUM 930,568 TOTAL ESTIMATED ANNUAL PREMIUM 930,568 TOTAL DUE 930,568 WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 GEORGIA ------------------------------- - --------------- --------------- STATE EMPLOYER/UNEMPLOYER ID POLICY PREFIX & NO. SCHEDULE ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. PRINTING 4299 6,500 4,09 266 PLASTICS MFG: MOLDED PRODUCTS NOC 4484 31,900 7,50 2,393 PAINT MFG 4558 1,600 6.81 109 AWNING, TENT OR CANVAS GOODS ERECTION 5102 12,100 8.17 989 REMOVAL OR REPAIR & DRIVERS FURNITURE OR FIXTURES INSTALLATION - 5146 163,800 6.39 10,467 PORTABLE - NOC PLUMBING NOC & DRIVERS 5183 2,400 6.63 159 CABLE INSTALLATION & DRIVERS 5190 12,900 7.00 903 CONCRETE CONSTRUCTION NOC 5213 5,500 14.06 773 CONCRETE OR CEMENT WORK - FLOORS, 5221 5,400 11.18 604 DRIVEWAYS, YARDS OR SIDEWALKS - & DRIVERS CARPENTRY - INSTALLATION OF FINISHED 5437 750 9.54 72 WOODEN FLOORING SHEET ROCK INSTALLATION - WITHIN 5445 5,400 10.86 586 BUILDINGS - & DRIVERS PAINTING OR PAPER HANGING NOC & SHOP 5474 7,540 12.71 958 OPERATIONS, DRIVERS EATING AND AIR CONDITIONING DUCT 5536 6,500 11.34 737 WORKSHOP AND OUTSIDE-& DRIVERS CLEANER - DEBRIS REMOVAL 5610 837,400 9.25 77,460 CARPENTRY-DWELLINGS-THREE STORIES 5651 1,200 18.47 222 OR LESS WOOD SUNDRIES MFG.N O C - NO CEREAL 6504 100,200 5.33 5,341 MILLING CHAUFFEURS & HELPERS NOC COMMERCIAL 7380 24,000 8.50 2,040 WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 GEORGIA ------------------------------- - --------------- --------------- STATE EMPLOYER/UNEMPLOYER ID POLICY PREFIX & NO. SCHEDULE ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. DRIVERS, CHAUFFEURS AND THEIR HELPERS 7380 9,900 8.50 842 NOC-COMMERCIAL ALE OR BEER DEALER - WHOLESALE - & 7390 600 4.51 27 DRIVERS AUTOMOBILE RENTAL CO: 8002 37,600 3.19 1,199 ALL OTHER EMPLOYEES & COUNTER PERSONNEL, DRIVERS STORE: SHOE - RETAIL 8008 9,600 2.82 271 STORE: HARDWARE 8010 60 3.52 2 STORE: RETAIL NOC 8017 54,600 3.06 1,671 STORE: WHOLESALE NOC 8018 451,700 5.62 25,386 FURNITURE STORES -- WHOLESALE OR RETAIL - 8044 15,800 5.68 897 & DRIVERS ICE DEALER & DRIVERS 8203 11,200 11.71 1,312 CONTRACTOR'S PERMANENT YARD 8227 14,600 5.68 829 LUMBER YARD - NEW MATERIALS ONLY: 8232 38,300 9.49 3,635 ALL OTHER EMPLOYEES & YARD, WAREHOUSE, DRIVERS SASH, DOOR OR ASSEMBLED MILLWORK 8235 1,500 7.45 112 DEALER & DRIVERS RUBBER STOCK DEALER - USED - AND 8264 600 15.40 92 DRIVERS NPD STORAGE WAREHOUSE NOC 8292 665,400 9.28 61,749 STORAGE WAREHOUSE - FURNITURE - & 8293 4,700 13.82 650 DRIVERS AUTOMOBILE STORAGE GARAGE OR PARKING 8392 25,900 5.99 1,551 STATION & DRIVERS ___BONDED WAREHOUSING - ALL EMPLOYEES 8710 17,400 4.81 837 WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 GEORGIA ------------------------------- - --------------- --------------- STATE EMPLOYER/UNEMPLOYER ID POLICY PREFIX & NO. SCHEDULE ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. & CLERICAL SALESPERSONS, COLLECTORS OR 8742 168,400 0.90 1,516 MESSENGERS - OUTSIDE AUDITOR, ACCOUNTANT OR FACTORY COST 8803 24,800 0.21 52 OR OFFICE SYSTEMATIZER - TRAVELING CLERICAL OFFICE EMPLOYEES NOC 8810 9,060,100 0.50 45,301 PHYSICIAN & CLERICAL 8832 61,300 0.42 257 BUILDINGS-OPERATION BY CONTRACTORS 9014 21,400 7.10 1,519 BUILDINGS-OPERATION BY OWNER OR LESSEE 9015 300 7.05 21 HOTEL - ALL EMPLOYEES & SALESPERSON & 9052 84,100 5.39 4,533 DRIVERS COLLEGE: ALL OTHER EMPLOYEES 9101 297,000 6.26 18,592 CARPET INSTALLATION 9521 2,100 10.36 218 UNMODIFIED PREMIUM 361,413 INCREASED LIMITS-EMPLOYER LIABILITY 3.3% 9812 11,927 LOSS REIMBURSEMENT $250,000 9962 - 207,281 TOTAL UNMODIFIED PREMIUM 166,059 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 - 34,872 MODIFIED STANDARD PREMIUM 131,187 UNDISCOUNTED PREMIUM 131,187 TOTAL ESTIMATED ANNUAL PREMIUM 131,187 TOTAL DUE 131,187 WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 IOWA ------------------------------- - --------------- --------------- STATE EMPLOYER/UNEMPLOYER ID POLICY PREFIX & NO. SCHEDULE ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. OUTSOURCE INTERNATIONAL, INC. NEED ADDRESS ENTIRE STATE, IA 99999 FARM: NURSERY EMPLOYEES & DRIVERS 0005 200 3.77 8 INCLUDES INCIDENTAL LANDSCAPE GARDENING TEXTILE FIBER MFG - SYNTHETIC 2305 2,400 1.88 45 IRON OR STEEL: MANUFACTURING 3018 100 5.36 5 ROLLING MILL NOC & DRIVERS IRON OR STEEL WORKS - SHOP - 3030 14,300 7.10 1,015 STRUCTURAL IRON WORKS - SHOP - DECORATIVE & 3041 1,000 4.26 43 ___RIES PAPER MFG 4239 23,300 2.42 564 PHONOGRAPH RECORD MFG 4431 150 3.77 6 FOOD SUNDRIES MFG.N O C - NO CEREAL 6504 2,300 2.24 52 MILLING DRIVERS, CHAUFFEURS AND THEIR HELPERS 7380 200 3.64 7 NOC-COMMERCIAL STORAGE WAREHOUSE NOC 8292 400 5.40 22 CLERICAL OFFICE EMPLOYEES NOC 8810 79,600 0.29 231 HOSPITAL: ALL OTHER EMPLOYEES 9040 16,600 3.44 571 - -------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 IOWA 40 - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY UNMODIFIED PREMIUM 2,569 INCREASED LIMITS-EMPLOYER LIABILITY 3.3% 9812 85 TOTAL UNMODIFIED PREMIUM 2,654 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 - 557 MODIFIED STANDARD PREMIUM 2,097 LOSS REIMBURSEMENT $250,000 9862 - 1,165 UNDISCOUNTED PREMIUM 932 TOTAL ESTIMATED ANNUAL PREMIUM 932 TOTAL DUE 932 WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 ILLINOIS - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY LABOR WORLD OF AMERICA, INC. 449 S. ADDISON RD. ADDISON, IL 60101 FARM: NURSERY EMPLOYEES & DRIVERS 0005 249,900 5.47 13,670 INCLUDES INCIDENTAL LANDSCAPE GARDENING FARM: DAIRY & DRIVERS 0036 1,000 9.90 99 LANDSCAPE GARDENING & DRIVERS 0042 28,700 8.60 2,468 CODES 0042 AND 9102 PARK NOC MAY BE ASSIGNED TO THE SAME RISK. THE PAYROLL OF AN INDIVIDUAL EMPLOYEE MAY BE DIVIDED AND ALLOCATED BETWEEN CODES 0042 AND _____2 PROVIDED THAT THE ENTRIES ON THE __INAL RECORDS OF THE INSURED DISCLOSED ALLOCATION OF EACH INDIVIDUAL'S PAYROLL. AN ESTIMATE OR PERCENTAGE ALLOCATION OF PAYROLL IS NOT PERMITTED. FARM MACH OPERATIONS - BY CONTRACTORS - 0050 2,100 8.20 172 & DRIVERS TREE PRUNING, SPRAYING, REPAIRING, 0106 100 20.24 20 & DRIVERS DOMESTIC SERVICE CONTRACTOR - INSIDE 0917 143,000 8.78 12,555 CEMENT MFG 1701 600 5.65 34 EMERY WORKS & DRIVERS 1747 1,600 5.60 90 DIE CASTING MFG. 1925 43,000 7.55 3,247 CRACKER MFG. 2001 17,400 4.96 863 BAKERY & DRIVERS, ROUTE SUPERVISORS 2003 245,300 5.05 12,388 BREAKFAST FOOD MFG. 2016 3,800 1.33 51 ICE CREAM MFG & SALESMEN, DRIVERS 2039 5,300 4.88 259 - --------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 ILLINOIS - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY CONFECTION MFG 2041 82,400 4.32 3,560 PACKING HOUSE - ALL OPERATIONS NPD 2089 82,100 8.31 6,823 CANNERY NOC 2111 71,900 6.31 4,537 BREWERY & DRIVERS 2121 2,100 3.77 79 BOTTLING - NOT CARBONATED LIQUIDS OR 2156 37,600 5.67 2,132 SPIRITOUS LIQUORS - & ROUTE SUPERVISORS, DRIVERS NPD CANNING OR BOTTLING OF CARBONATED 2157 213,000 7.51 15,996 BEVERAGES EMBROIDERY MFG. 2388 22,100 3.60 796 _____ING MFG. 2501 245,700 3.45 8,477 HAIR GOODS MFG. 2534 124,400 5.45 6,780 MATTRESS OR BOX SPRING MFG. 2570 300 8.51 26 AWNING OR TENT MFG - SHOP 2576 16,000 6.23 997 LAUNDRY NOC & ROUTE SUPERVISORS, 2585 55,400 6.60 3,656 SALESMEN, DRIVERS CLEANING OR DYEING & ROUTE SUPERVISORS, 2586 174,200 2.26 3,937 SALESMEN, DRIVERS DRY CLEANING AND LAUNDRY STORE - RETAIL 2589 27,200 3.34 908 __ & ROUTE SUPERVISORS, SALESMEN, DRIVERS HOE STOCK MFG. 2651 3,000 5.27 158 LEATHER GOODS MFG, NOC 2688 45,000 4.39 1,976 FURNITURE STOCK MFG. 2735 79,600 9.83 7,825 BOX, BOX SHOOK OR PALLET MFG. 2759 66,100 14.76 9,756 _OODEN _______-MAKING NOC NPD 2790 6,000 2.38 143 - ----------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 GEORGIA - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY OUTSOURCE INTERNATIONAL, INC. 6049 A NEW PEACHTREE RD. DORAVILLE, GA 30345 CLERICAL OFFICE EMPLOYEES NOC 8810 625,400 0.50 3,127 LABOR WORLD OF AMERICA, INC. 1030 WINDY HILL ROAD, S.E. SMYRNA, GA 30080 FARM: NURSERY EMPLOYEES & DRIVERS 0005 1,000 7.19 72 INDLUDES INCIDENTAL LANDSCAPE GARDENING LANDSCAPE GARDENING & DRIVERS 0042 14,000 13.16 1,842 CODES 0042 AND 9102 PARK NOC MAY BE ASSIGNED TO THE SAME RISK. THE PAYROLL OF AN INDIVIDUAL EMPLOYEE MAY BE DIVIDED AND ALLOCATED BETWEEN CODES 0042 AND 9102 PROVIDED THAT THE ENTRIES ON THE ORIGNAL RECORDS OF THE INSURED DISCLOSE AN ALLOCATION OF EACH INDIVIDUAL'S PAYROLL. AN ESTIMATE OR PERCENTAGE ALLOCATION OF PAYROLL IS NOT PERMITTED. DOMESTIC SERVICE CONTRACTOR - INSIDE 0917 200 7.74 15 TEXTILE FIBER MFG - SYNTHETIC 2305 36,800 3.86 1,420 CARPET OR RUG MFG NOC 2402 11,100 10.02 1,112 CLOTHING MFG. 2501 47,200 4.23 1,997 LAUNDRY NOC & ROUTE SUPERVISORS, 2585 348,200 6.87 23,921 SALESMEN, DRIVERS CLEANING OR DYEING & ROUTE SUPERVISORS, 2586 22,300 3.80 847 SALESMEN, DRIVERS _______ MFG-LEATHER OR TEXTILE 2670 2,000 4.49 90 - --------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 ILLINOIS - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY CARPENTRY SHOP ONLY AND DRIVERS 2802 13,700 8.91 1,221 CABINET WORKS - WITH POWER MACHINERY 2812 99,600 5.75 5,727 BRUSH OR BROOM MFG NOC 2836 11,700 7.59 888 FURNITURE ASSEMBLING-WOOD-FROM 2881 90,700 6.73 6,104 MANUFACTURED PARTS FURNITURE MFG - WOOD - NOC 2883 143,400 6.29 9,020 IRON OR STEEL: MANUFACTURING 3018 10,000 7.72 772 ROLLING MILL NOC & DRIVERS PIPE OR TUBE MFG NOC & DRIVERS 3022 13,700 6.66 912 _____ OR STEEL WORKS - SHOP - STRUCTURAL 3030 9,200 14.43 1,328 SIGN MFG - METAL 3064 16,600 7.21 1,197 SHEET METAL WORK - SHOP 3066 66,600 6.49 4,322 FIREPROOF EQUIPMENT MFG 3076 454,100 7.69 34,920 FOUNDRY - FERROUS - NOC 3081D 300 12.48 37 FOUNDRY - NON-FERROUS 3085D 211,200 13.24 27,963 TOOL MFG - NOT DROP OR MACHINE FORGED - 3113 84,500 3.18 2,687 NOC TOOL MFG - DROP OR MACHINE FORGED - NOC: 3114 140,200 5.28 7,403 MACHINING OR FINISHING OF TOOLS OR DIE MACHINE OPERATIONS TOOL MFG - AGRICULTURAL, CONSTRUCTION, 3126 1,200 8.76 105 LOGGING, MINING, OIL OR ARTESIAN WELL BUTTON OR FASTENER MFG-METAL 3131 947,800 3.16 29,950 BOLT OR NUT MFG. 3132 628,900 8.11 51,004 AUTOMATIC SCREW MACHINE PRODUCTS 3145 210,000 3.20 6,720 _____________ N.P.D. - ---------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 ILLINOIS - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY HARDWARE MFG. N.O.C. 3146 440,800 5.50 24,244 RADITOR OR HEATER MFG 3175D 4,700 4.00 188 ELECTRICAL APPARATUS MFG NOC 3179 1,466,900 4.59 67,331 ELECTRIC OR GAS LIGHTING FIXTURES MFG. 3180 24,500 4.83 1,183 PLUMBERS' SUPPLIES MFG NOC 3188 3,700 2.48 92 CAN MFG 3220 527,200 5.13 27,045 ALUMINUM WARE MFG 3227 71,900 5.42 3,897 WIRE DRAWING-IRON OR STEEL 3241 4,900 9.01 441 _____ GOODS MFG NOC 3257 813,700 4.76 38,732 TACK MFG 3270 4,700 4.57 215 SPRING MFG 3303 26,200 7.11 1,863 HEAT TREATING-METAL-N P D 3307 1,600 6.24 100 BRASS OR COPPER GOODS MFG 3315 7,500 4.07 305 WELDING OR CUTTING NOC & DRIVERS 3365 24,800 13.41 3,326 ELECTROPLATING NPD 3372 279,300 5.39 15,054 WATCH MFG 3385 92,600 2.70 2,500 METAL GOODS MFG. NOC 3400 4,601,100 6.63 305,053 CONSTRUCTION OR AGRICULTURAL MACHINERY 3507 321,800 7.51 24,167 MFG PRINTING MACHINE MFG. 3548 1,864,300 3.59 66,928 COMPUTING, RECORDING OR OFFICE MACHINE 3574 79,400 2.93 2,326 MFG NOC ______ MFG 3612 309,500 4.72 14,608 - -------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 ILLINOIS - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY PRECISION MACHINED PARTS MFG.-NOC 3629 153,700 3.56 5,472 MACHINE SHOP NOC 3632 1,404,300 6.01 84,398 VALVE MFG 3634 18,000 5.41 974 GEAR MFG OR GRINDING - N P D 3635 27,300 5.20 1,420 BALL OR ROLLER BEARING MFG 3638 40,200 2.54 1,021 ELECTRIC POWER OR TRANSMISSION EQUIPMENT 3643 5,800 4.96 288 MFG BATTERY MFG-STORAGE 3647 150 5.25 8 AUTOMOTIVE LIGHTING IGNITION OR STARTING 3648 26,600 5.63 1,498 APARATUS MFG NOC RADIO APPRATUS MFG OR ASSEMBLY NOC 3681 1,529,700 2.65 40,537 INSTRUMENT MFG NOC 3685 162,100 2.94 4,766 ELECTRICAL APPRATUS INSTALLATION OR 3724 15,000 13.61 2,042 REPAIR & DRIVERS AUTOMOBILE MFG 3808 600 5.97 36 MOTORCYCLE MFG OR ASSEMBLY 3851 1,500 6.16 92 BRICK OR CLAY PRODUCTS MFG NOC & DRIVERS 4021 29,400 9.13 2,684 PLASTER BOARD OR PLASTER BLOCK MFG & 4036 24,900 4.03 1,003 DRIVERS PLASTER STATUARY OR ORNAMENT MFG 4038 25,800 6.60 1,703 LIGHT BULB MFG 4112 39,100 2.54 993 INCLUDES INCANDESCENT FLOURESCENT, X-RAY, TELEVISION OR CATHODE TUBE MFG. OPTICAL GOODS MFG NOC 4150 3,000 2.32 70 ______ MFG 4239 3,500 5.12 179 - -------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 ILLINOIS - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY BOX MFG - FOLDING PAPER - NOC 4243 74,000 5.65 4,181 CORRUGATED OR FIBER BOARD CONTAINER MFG 4244 1,000 6.75 68 PAPER COATING 4250 238,000 4.39 10,448 LOOSE-LEAF LEDGER OR NOTE BOOK MFG 4251 341,600 5.52 18,856 BAG MFG - PAPER 4273 14,900 6.62 986 PAPER GOODS MFG NOC 4279 900,100 4.58 41,225 DRESS PATTERN MFG - PAPER -& CLERICAL 4282 29,000 3.01 873 PRINTING 4299 1,114,700 4.57 50,942 BOOK BINDING 4307 773,100 3.62 27,986 MOTION PICTURE: DEVELOPMENT OF 4360 1,500 1.32 20 NEGATIVES, PRINTING AND ALL SUBSEQUENT OPERATIONS BLUEPRINT REPRODUCTION - ALL EMPLOYEES & 4361 8,100 1.54 125 SALESPERSONS, DRIVERS RUBBER GOODS MFG N O C 4410 1,092,200 6.45 70,447 PLASTICS MFG: FABRICATED PRODUCTS NOC 4452 111,100 5.50 6,111 WIRE INSULATING OR COVERING 4470 35,400 9.05 3,204 PLASTICS MFG. - MOLDED PROD. NOC 4484 7,820,000 4.85 379,270 CANDLE MFG NPD 4557 737,600 4.46 32,897 PAINT MFG 4558 55,200 3.07 1,695 DRUG MEDICINE OR PHARMACEUTICAL PREP. 4611 1,167,300 2.72 31,751 TO MFG. OF INGREDIENTS GLUE MFG & DRIVERS NPD 4653 600 3.27 20 PHARMACEUTICAL OR SURGICAL GOODS MFG NOC 4693 100 2.45 2 - -------------------------------------------------------------------------------------------------------------- WC 7754 (Ed 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 ILLINOIS - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY DEXTRINE MFG. 4703 12,700 4.76 605 SOAP OR SYNTHETIC DETERGENT MFG 4720 854,300 6.40 54,675 OIL REFINING - PETROLEUM - & DRIVERS 4740 8,000 3.23 258 EXTRACT MFG - DYEWOOD 4825 29,100 2.67 777 CHEMICAL BLENDING OR MINING NOC - ALL 4828 257,800 3.63 9,358 OPERATIONS & DRIVERS SPORTING GOODS MFG NOC 4902 5,000 3.49 175 AUDIO OR VISUAL RECORDING MEDIA MFG 4923 11,600 2.82 327 INCLUDES TAPES OR DISKS, PHONOGRAPH RECORD MFG. TO BE SEPARATELY RATED _____ CODE 4431. MASONRY NOC 5022 1,000 19.35 194 TENT ERECTION & DRIVERS 5102 4,000 21.30 852 FURNITURE OR FIXTURES INSTALLATION - 5146 70,900 11.46 8,125 PORTABLE - NOC PLUMBING NOC & DRIVERS 5183 2,000 12.07 241 OFFICE MACHINE OR APPLIANCE 5191 11,200 2.03 227 INSTALLATION, INSPECTION, ADJUSTMENT OR REPAIR VENDING OR COIN OPERATED 5192 700 4.52 32 MACHINES-INSTALLATION SERVICE OR REPAIR-INCLUDING SALESMEN DRIVERS FENCE ERECTION - WOOD NOC 5403 6,200 19.18 1,189 CARPENTRY - INSTALLATION OF FINISHED 5437 9,400 10.45 982 WOODEN FLOORING SHEET ROCK INSTALLATION - WITHIN 5445 8,100 9.26 750 BUILDING - & DRIVERS ___________ WORK NOC & DRIVERS 5479 21,600 21.27 4,594 - --------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 ILLINOIS - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY STREET OR ROAD CONSTRUCTION OR 5506 48,400 10.85 5,251 RECONSTRUCTION & DRIVERS FILLING OR GRADING TUNNELING BRIDGE OR CULVERT TO BE SEPARATELY RATED FILLING OR GRADING TUNNELING BRIDGE OR CULVERT BUILDING QUARRYING STONE CRUSHING TO BE SEPARATELY RATED SHEET METAL WORK - SHOP AND OUTSIDE - & 5538 700 14.19 99 NOC & DRIVERS CLEANER - DEBRIS REMOVAL 5610 656,900 8.00 52,552 CARPENTRY - DETACHED ONE OR TWO FAMILY 5645 26,100 15.95 4,163 DWELLINGS CARPENTRY - DWELLINGS - THREE STORIES 5651 700 15.78 110 OR LESS SALVAGE OPERATION - NO WRECKING OR ANY 5705 2,300 10.97 252 STRUCTURAL OPERATIONS DRILLING NOC & DRIVERS NPD 6204 150 18.39 28 GRADING OF LAND NOC & DRIVERS 6217 5,500 8.69 478 FOOD SUNDRIES MFG. NOC - NO CEREAL 6504 10,646,300 4.99 531,250 MILLING TRUCKING - LOCAL HAULING ONLY - & DRIVERS 7228 43,600 13.58 5,921 TRUCKING: 7230 6,000 11.68 701 PARCEL OR PACKAGE DELIVERY - ALL EMPLOYEES & DRIVERS TRUCKING: 7231 1,900 8.98 171 MAIL, PARCEL OR PACKAGE DELIVERY - ALL EMPLOYEES & DRIVERS CHAUFFEURS, DRIVERS & THEIR HELPERS 7380 199,000 7.64 15,204 NOC - COMMERCIAL AT_____WORKS OPERATION & SALESMEN, DRIVERS 7520 11,700 5.94 695 - --------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 ILLINOIS - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY GARBAGE WORKS 7590 365,000 8.00 29,200 FLORIST - STORE - DRIVERS 8001 14,800 2.68 397 STORE: FRUIT OR VEGETABLE - RETAIL 8006 16,700 3.39 566 STORE: CLOTHING, WEARING APPAREL OR DRY 8008 19,300 1.38 266 GOODS - RETAIL STORE: HARDWARE 8010 816,300 2.99 24,407 STORE: RETAIL NOC 8017 2,062,700 2.36 48,680 FRUIT OR VEGETABLE STORES - WHOLESALE 8018 10,398,700 5.40 561,530 STORE: MEAT, FISH OR POULTRY DEALER - 8021 593,800 6.20 36,816 ______ - SALE STORE: MEAT, FISH OR POULTRY - RETAIL 8031 1,500 3.82 57 STORE: CLOTHING, WEARING APPEAREL OR DRY 8032 269,800 2.76 7,446 GOODS - WHOLESALE DEPARTMENT STORES--RETAIL 8039 2,300 1.70 39 FURNITURE STORES--WHOLESALE OR RETAIL - 8044 33,400 4.20 1,403 & DRIVERS AUTOMOBILE ACCESSORY STORES - RETAIL - 8046 3,400 2.68 91 NOC - & DRIVERS BUILDING MATERIAL DEALER - NEW MATERIALS 8058 235,400 2.99 7,038 ONLY: STORE EMPLOYEES METAL MERCHANT & DRIVERS 8106 122,000 8.65 10,553 APPLIES TO DEALERS OF IRON, STEEL OR NONFERROUS METAL. MACHINERY DEALER NOC - STORE OR YARD - 8107 262,300 6.53 17,128 & DRIVERS ______ERS' SUPPLIES DEALER & DRIVERS NPD 8111 4,800 5.94 285 - --------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 ILLINOIS - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY LUMBER YEAR - NEW MATERIALS ONLY: 8232 75,100 8.25 6,196 ALL OTHER EMPLOYEES & YARD, WAREHOUSE, DRIVERS SASH, DOOR OR ASSEMBLED MILLWORK 8235 1,000 6.36 64 DEALER & DRIVERS PAPER STOCK OR RAG DEALER - USED - & 8264 759,900 10.50 79,790 DRIVERS NPD STORAGE WAREHOUSE - COLD 8291 209,300 6.84 14,316 STORAGE WAREHOUSE NOC 8292 17,100 7.85 1,342 STORAGE WAREHOUSE - FURNITURE - & 8293 55,800 15.92 8,883 DRIVERS _______ GASOLINE DEALER & DRIVERS 8350 8,200 7.19 590 AUTOMOBILE SERVICE OR REPAIR CENTER 8380 29,700 4.60 1,366 AND DRIVERS AUTOMOBILE STORAGE GARAGE OR PARKING 8392 1,200 3.08 37 STATION & DRIVERS AUTOMOBILE BODY REPAIR 8393 11,600 3.35 389 SALESPERSONS, COLLECTIONS OR MESSENGERS - 8742 1,636,700 0.62 10,148 OUTSIDE AUTOMOBILE SALESMEN 8748 4,700 0.75 35 ADDRESSING OR MAILING CO & CLERICAL 8800 776,500 3.23 25,081 CLERICAL OFFICE EMPLOYEES NOC 8810 10,625,000 0.31 32,938 RETIREMENT LIVING CENTERS: 8825 600 2.43 15 FOOD SERVICE EMPLOYEES CHARITABLE OR WELFARE 8861 900 0.61 5 ORGANIZATION: PROFESSIONAL EMPLOYEES & CLERICAL JANITORIAL SERVICE BY CONTRACTOR 9014 1,557,900 6.09 94,876 - ---------------------------------------------------------------------------------------------------------------- WC (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 ILLINOIS - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY BUILDING NOC - OPERATION BY OWNER OR 9015 150,400 4.72 7,099 LESSEE AMUSEMENT PARK OR EXHIBITION 9016 17,800 4.51 803 OPERATION & DRIVERS HOUSING AUTHORITY & CLERICAL, SALESMEN, 9033 6,400 6.37 408 DRIVERS HOSPITAL: ALL OTHER EMPLOYEES 9040 4,400 5.31 234 HOTEL - ALL EMPLOYEES & SALESMEN & 9052 106,900 4.21 4,500 DRIVERS HOTEL: RESTAURANT EMPLOYEES 9058 72,200 2.43 1,754 ______-COUNTRY, GOLF, FISHING OR YACHT - 9060 20,400 2.62 534 & CLERICAL RESTAURANT NOC 9082 87,900 3.15 2,769 LAWN MAINTENANCE - COMMERCIAL OR 9102 7,100 4.37 310 DOMESTIC & DRIVERS CODES 9102 AND 0042, LANDSCAPE GARDENING AND DRIVERS MAY BE ASSIGNED TO THE SAME RISK, THE PAYROLL OF AN INDIVIDUAL EMPLOYEE MAY BE DIVIDED AND ALLOCATED BE- TWEEN CODES 0042 AND 9102 PROVIDED THAT THE ENTRIES ON THE ORIGINAL RECORDS OF THE INSURED DISCLOSE AN ALLOCATION OF EACH INDIVIDUAL'S PAYROLL. AN ESTIMATE OR PERCENTAGE ALLOCATION OF PAYROLL IS NOT PERMITTED. CHARITABLE OR WELFARE 9110 1,000 4.81 48 ORGANIZATION: ALL OTHER EMPLOYEES & DRIVERS THEATERE NOC: ALL OTHER EMPLOYEES 9154 1,500 2.51 38 ATHLETIC TEAM OR PARK: OPERATION & 9182 3,000 7.62 229 DRIVERS STREET CLEANING & DRIVERS 9402 35,600 9.56 3,403 - --------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 ILLINOIS - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY ASHES, GARBAGE OR REFUSE COLLECTION & 9403 78,800 11.00 8,668 TOWNSHIP EMPLOYEES N O C 9410 101,200 4.13 4,180 PAINTING: SHOP ONLY & DRIVERS NPD 9501 131,200 4.88 6,403 VIDEO, TELEVISION, RADIO AND AUDIO 9516 6,600 4.99 329 EQUIPMENT INSTALLATION, SERVICE OR REPAIR & DRIVERS HOUSEHOLD APPLIANCES - ELECTRICAL - 9519 13,200 4.99 659 INSTALLATION, SERVICE OR REPAIR - & DRIVERS. CARPET INSTALLATION 9521 10,200 9.54 973 UPOLSTERING NPD 9522 15,900 3.97 631 UNMODIFIED PREMIUM 3,512,828 INCREASED LIMITS-EMPLOYER LIABILITY 3.3% 9812 115,923 TOTAL UNMODIFIED PREMIUM 3,628,751 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 (762,038) SCHEDULE MODIFICATION 25% 9887 (716,678) MODIFIED STANDARD PREMIUM 2,150,035 LOSS REIMBURSEMENT $250,000 9862 (1,142,504) UNDISCOUNTED PREMIUM 1,007,531 TOTAL ESTIMATED ANNUAL PREMIUM 1,007,531 TOTAL DUE 1,007,531 - --------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 INDIANA - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY SYNADYNE I JOBSITE ONLY FREEMONT, IN 46737 CLERICAL OFFICE EMPLOYEES NOC 8810 1,233,222 0.23 2,836 LABOR WORLD OF AMERICA, INC. 6935 GRAND AVENUE HAMMOND, IN 46323 FARM: NURSERY EMPLOYEES & DRIVERS 0005 4,500 3.58 161 INCLUDES INCIDENTAL LANDSCAPE GARDENING SMELTING - ELECTRIC PROCESS - & DRIVERS 1438 14,400 2.94 423 CANNERY NOC 2111 900 2.58 23 COTTON BATTING, WADDING OR WASTE MFG. 2211 300 4.98 15 AWNING OR TENT MFG - SHOP 2576 8,200 3.11 255 LAUNDRY NOC & ROUTE SUPERVISORS, 2585 6,400 2.89 185 SALESMEN, DRIVERS PATTERN-MAKING NOC NPD 2790 63,100 1.37 864 CARPENTRY SHOP ONLY AND DRIVERS 2802 102,000 4.85 4,947 FURNITURE ASSEMBLING-WOOD-FROM 2881 20,800 3.36 699 MANUFACTURED PARTS VENEER PRODUCTS MFG 2915 174,300 5.89 10,266 IRON OR STEEL: MANUFACTURING 3018 5,600 2.45 137 ROLLING MILL NOC & DRIVERS ____ OR TUBE MFG NOC & DRIVERS 3022 17,400 3.24 564 ____ WORKS - SHOP - DECORATIVE & 3041 400 2.93 12 FOUNDRIES - ---------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 INDIANA - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY METAL EQUIPMENT MFG 3076 93,000 3.27 3,041 FOUNDRY - NON-FERROUS 3085D 34,100 3.36 1,146 PIPE BENDING AND CUTTING 3111 2,600 3.31 86 SCREW MFG 3145 50,200 1.48 743 ELECTRICAL APPARATUS MFG NOC 3179 11,100 2.04 226 ELECTRIC OR GAS LIGHTING FIXTURES MFG. 3180 2,200 2.45 54 ALUMINUM WARE MFG 3227 2,500 2.99 75 WIRE GOODS MFG NOC 3257 34,000 2.98 1,013 BOX SPRING OR WIRE MATTRESS MFG 3300 53,600 3.36 1,801 BRASS OR COPPER GOODS MFG 3315 9,900 3.28 325 METAL STAMPING MFG 3400 49,400 3.58 1,769 APPLICABLE TO MASS PRODUCTION MANUFACTURING OF STAMPED METAL ARTICLES INCLUDING, BUT NOT LIMITED TO, LICENSE PLATES, TAGS, TOYS,PIE PLATES, BUCKETS AND WASTE BASKETS. AGRICULTURAL OR CONSTRUCTION MACHINERY 3507 10,600 2.64 280 MFG COMPUTING, RECORDING OR OFFICE MACHINE 3574 500 1.14 6 MFG NOC PRECISION MACHINED PARTS MFG NOC NPD 3629 3,400 1.07 36 MACHINE SHOP NOC 3632 100,700 2.23 2,246 ELECTRIC POWER OR TRANSMISSION EQUIPMENT 3643 41,100 1.47 604 MFG LOCOMOTIVE LIGHTING IGNITION OR STARTING 3648 21,500 4.36 93 ______RATUS MFG NOC RADIO APPARATUS MFG OR ASSEMBLY NOC 3681 99,900 2.98 2,97 - --------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INDURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 INDIANA - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY AUTO,BUS,TRUCK,OR,TRAIL.-NOC 3824 40,300 5.13 2,067 CONCRETE PRODUCTS MFG & DRIVERS 4034 57,900 5.21 3,017 PAPER CREPEING 4250 600 1.77 11 BAG MFG - PAPER 4273 4,100 2.16 89 RUBBER GOODS MFG N 0 C 4410 120,600 2.67 3,220 PLASTICS MFG: MOLDED PRODUCTS NOC 4484 384,300 2.50 9,608 COMPUTER DEVICE INSTALLATION 5191 5,400 0.88 48 INSPECTION SERVICE OR REPAIR INCLUDES SHOP OPERATIONS. COMPUTER MFG. TO BE SEPARATELY ________ED. FENCE ERECTION - WOOD NOC 5403 1,200 6.97 84 PAINTING OR PAPER HANGING NOC & SHOP 5474 4,700 4.61 217 OPERATIONS, DRIVERS STREET OR ROAD CONSTRUCTION & DRIVERS 5507 300 2.78 8 TIMEKEEPERS-CONSTRUCTION OR ERECTION 5610 49,700 4.52 2,246 DRIVERS, CHAUFFEURS AND THEIR HELPERS 7380 15,500 2.52 391 NOC-COMMERCIAL BEER OR ALE DEALER- WHOLESALE- & 7390 44,500 4.48 1,994 DRIVERS GARBAGE WORKS 7590 20,100 7.10 1,427 STORE: HARDWARE 8010 22,200 1.29 286 STORE: RETAIL NOC 8017 150 1.15 2 STORE: WHOLESALE NOC 8018 12,000 2.89 347 FURNITURE STORES --WHOLESALE OR RETAIL 8044 10,100 2.14 216 DRIVERS - ---------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 INDIANA - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY METAL MERCHANT & DRIVERS 8106 8,l00 4.44 360 APPLIES TO DEALERS OF IRON, STEEL OR NONFERROUS METAL. MACHINERY DEALER NOC - STORE OR YARD 8107 900 2.70 24 & DRIVERS SASH, DOOR OR ASSEMBLED MILLWORK 8235 9,100 3.25 296 DEALER & DRIVERS BOTTLE DEALER -USED- & DRIVERS 8264 16,000 6.58 1,053 IRON SCRAP DEALER NPD 8265 2,600 5.50 143 STORAGE WAREHOUSE NOC 8292 4,600 4.19 193 AUTOMOBILE CAR WASH AND DRIVERS 8380 65,500 2.17 1,421 METAL SCRAP DEALER & DRIVERS NPD 8500 11,150 6.00 669 ADDRESSING OR MAILING CO & CLERICAL 8800 1,300 3.08 40 CLERICAL OFFICE EMPLOYEES NOC 8810 241,700 0.23 556 THEATRE NOC: PLAYERS, ENTERTAINERS OR 9156 150 1.12 2 MUSICIANS PAINTING: SHOP ONLY & DRIVERS NPD 9501 10,800 2.40 259 HOUSEHOLD APPLIANCES - ELECTRICAL 9519 1,500 1.72 26 INSTALLATION, SERVICE OR REPAIR - & DRIVERS. AUTOMOBILE, BUS, TRUCK, OR TRAILER 9522 70,200 2.05 1,439 BODY MFG: UPHOLSTERING - ----------------------------------------------------------------------------------------------------------------- WC 7754 (Ed.4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 INDIANA - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY UNMODIFIED PREMIUM 70,511 INCREASED LIMITS-EMPLOYER LIABILITY 3.3% 9812 2,327 TOTAL UNMODIFIED PREMIUM 72,838 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 (15,296) SCHEDULE MODIFICATION 50% 9887 (28,771) MODIFIED STANDARD PREMIUM 28,771 LOSS REIMBURSEMENT $250,000 9862 (15,415) UNDISCOUNTED PREMIUM 13,356 TOTAL ESTIMATED ANNUAL PREMIUM 13,356 TOTAL DUE 13,356 - ---------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 KENTUCKY - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY SYNADYNE I JOBSITE ONLY FORT KNOX, KY 40121 CLERICAL OFFICE EMPLOYEES NOC 8810 1,012,239 0.36 3,644 UNMODIFIED PREMIUM 3,644 INCREASED LIMITS-EMPLOYER LIABILITY 3.3% 9812 120 LOSS REIMBURSEMENT $250,000 9962 (2,024) TOTAL UNMODIFIED PREMIUM 1,740 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 (365) MODIFIED STANDARD PREMIUM 1,375 UNDISCOUNTED PREMIUM 1,375 TOTAL ESTIMATED ANNUAL PREMIUM 1,375 _____SMENTS/TAXES 9% 0088 268 TOTAL DUE 1,643 - --------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 LOUISIANA - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY SYNADYNE 1 2050 #100 CANAL ST NEW ORLEANS, LA 70112 CLERICAL OFFICE EMPLOYEES NOC 8810 2,799,000 0.72 20,158 LABOR WORLD OF AMERICA, INC. JOBSITE ONLY NEW ORLEANS, LA 70101 LANDSCAPE GARDENING & DRIVERS 0042 105,400 13.96 14,714 CODES 0042 AND 9102 PARK NOC MAY BE CONTINUED TO THE SAME RISK.THE PAYROLL OF AN INDIVIDUAL EMPLOYEE MAY BE DIVIDED AND ALLOCATED BETWEEN CODES 0042 AND 9102 PROVIDED THAT THE ENTRIES ON THE ORIGINAL RECORDS OF THE INSURED DISCLOSE AN ALLOCATION OF EACH INDIVIDUAL'S PAYROLL.AN ESTIMATE OR PERCENTAGE ALLOCATION OF PAYROLL IS NOT PERMITTED. SPIRITUOUS LIQUOR BOTTLING 2131 48,500 6.81 3,303 CARBONATED BEVERAGE MFG NOC & ROUTE 2157 1,000 7.54 75 SUPERVISORS, DRIVERS LAUNDRY NOC & ROUTE SUPERVISORS, 2585 2,200 7.76 171 SALESMEN, DRIVERS ARMS MFG NOC 3548 350 4.73 17 MACHINE SHOP NOC 3632 500 10.23 51 BOOKBINDING 4307 2,800 5.55 155 PLASTICS MFG: MOLDED PRODUCTS NOC 4484 44,300 7.65 3,389 OPERATE MACHINE OR APPLIANCE, 5191 58,600 2.63 1,541 INSTALLATION, INSPECTION, ADJUSTMENT OR REPAIR - ------------------------------------------------------------------------------------------------------------------ WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 LOUISANA - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY CLEANER - DEBRIS REMOVAL 5610 25,500 22.02 5,615 FOOD SUNDRIES MFG.N 0 C -NO CEREAL 6504 38,700 7.57 2,930 MILLING ARMORED CAR CREWS -- (NOT APPLICABLE) 7380 16,700 10.42 1,740 TO CONTRACTORS WHO PROVIDE SUCH SERVICES) -- & DRIVERS FLORIST-STORE-DRIVERS 8001 1,800 3.28 59 STORE: RETAIL NOC 8017 34,200 3.83 1,310 STORE: WHOLESALE NOC 8018 2,000 10.54 211 DEPARTMENT STORES--RETAIL 8039 150 3.64 5 AUTOMOBILE ACCESSORY STORES - RETAIL - 8046 4,400 4.06 179 N0C - & DRIVERS MACHINERY DEALER NOC - STORE OR YARD - 8107 1,000 10.54 105 & DRIVERS STORAGE WAREHOUSE 8292 10,000 10.25 1,025 N0C. APPLIES TO GENERAL MERCHANDISE STORAGE WAREHOUSE - FURNITURE - & 8293 2,200 18.54 408 DRIVERS AUTOMOBILE STORAGE GARAGE OR PARKING 8392 900 4.43 40 STATION & DRIVERS LETTER SERVICE SHOP & CLERICAL NPD 8800 7,600 5.92 450 CLERICAL OFFICE EMPLOYEES NOC 8810 4,000 0.72 29 BUILDINGS-OPERATION BY CONTRACTORS 9014 42,600 9.49 4,043 AMUSEMENT PARK OR EXHIBITION 9016 70,700 5.75 4,065 OPERATION & DRIVERS ______RANT NOC 9082 64,700 6.92 4,477 ASHES, GARBAGE OR REFUSE COLLECTION 9403 4,200 20.71 870 - --------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 LOUISANA - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY DRIVERS UNMODIFIED PREMIUM 71,135 INCREASED LIMITS-EMPLOYER LIABILITY 2% 9812 1,423 TOTAL UNMODIFIED PREMIUM 72,558 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 (15,237) MODIFIED STANDARD PREMIUM 57,321 LOSS REIMBURSEMENT $250,000 9862 (32,146) UNDISCOUNTED PREMIUM 25,175 TOTAL ESTIMATED ANNUAL PREMIUM 25,175 TOTAL DUE 25,175 - --------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 MASSACHUSETTS - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY OUTSOURCE INTERNATIONAL, INC. NEED ADDRESS ENTIRE STATE, MA 99999 BOTTLING NOC & ROUTE SUPERVISORS, 2157 35,400 8.36 2,959 DRIVERS YARN OR THREAD MFG - SILK 2302 4,100 5.66 232 CLOTHING MFG. 2501 600 4.06 24 SHOE OR BOOT MFG NOC 2660 6,800 3.54 241 SHADE ROLLER MFG - WOOD 2841 6,800 5.97 406 WIRE DRAWING-IRON OR STEEL 3241 20,200 5.64 1,139 ELECTROPLATING NPD 3372 4,300 4.60 198 METAL STAMPING MFG 3400 1,200 6.44 77 APPLICABLE TO MASS PRODUCTION MANUFACTURING OF STAMPED METAL ARTICLES INCLUDING, BUT NOT LIMITED TO, LICENSE PLATES, TAGS, TOYS,PIE PLATES, BUCKETS AND WASTE BASKETS. MACHINE SHOP NOC 3632 3,900 3.60 140 RADIO APPARATUS MFG OR ASSEMBLY NOC 3681 8,700 2.13 185 CORRUGATED OR FIBER BOARD CONTAINER MFG 4244 600 5.57 33 BAG MFG - PAPER & PLASTIC 4273 19,300 5.56 1,073 PRINTING 4299 182,900 3.25 5,944 MOTION PICTURE: DEVELOPMENT OF 4360 1,500 1.07 16 NEGATIVES, PRINTING AND ALL SUBSEQUENT OPERATIONS ____R GOODS MFG N 0 C 4410 19,800 4.87 964 - -------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 MASSACHUSETTS - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY BONE OR IVORY GOODS MFG 4452 27,000 4.36 1,177 WIRE INSULATING OR COVERING 4470 9,800 5.24 514 PLASTICS MFG: MOLDED PRODUCTS NOC 4484 236,600 5.16 12,209 CARPENTRY NOC 5403 5,600 22.82 1,278 SHEET METAL WORK-ERECTION INSTALLATION 5538 2,700 13.20 356 OR REPAIR N 0 C-SHOP AND OUTSIDE-INCLUDING DRIVERS SHEET METAL ROOFING ON SLOPING ROOFS TO BE SEPARATELY RATED TIMEKEEPERS-CONSTRUCTION OR ERECTION 5610 34,700 23.48 8,148 SUNDRIES MFG.N 0 C -NO CEREAL 6504 71,200 6.62 4,713 ______NG ELECTRIC LIGHT OR POWER CO NOC - ALL 7539 14,500 3.31 480 EMPLOYEES & SALESMEN, DRIVERS STORE: RETAIL NOC 8017 3,200 1.98 63 STORE: WHOLESALE - NOC 8018 125,600 6.79 8,528 FURNITURE STORES --WHOLESALE OR RETAIL - 8044 5,200 5.23 272 & DRIVERS SALESPERSONS, COLLECTORS OR MESSENGERS - 8742 44,900 0.53 238 OUTSIDE CLERICAL OFFICE EMPLOYEES NOC 8810 548,300 0.28 1,535 LAWN MAINTENANCE - COMMERCIAL OR 9102 100 4.37 4 DOMESTIC & DRIVERS CODES 9102 AND 0042, LANDSCAPE GARDENING AND DRIVERS MAY BE ASSIGNED TO THE SAME RISK. THE PAYROLL OF AN INDIVIDUAL EMPLOYEE MAY BE DIVIDED AND ALLOCATED BE- TWEEN CODES 0042 AND 9102 PROVIDED THAT THE ENTRIES ON THE ORIGINAL RECORDS OF _______ INSURED DISCLOSE AN ALLOCATION OF EACH INDIVIDUAL'S PAYROLL. AN ESTIMATE - ---------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 MASSACHUSETTS - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY OR PERCENTAGE ALLOCATION OF PAYROLL IS NOT PERMITTED. SIGN PAINT OR LETTERING INSIDE OF 9501 1,200 4.97 60 BUILDING- & DRIVERS UNMODIFIED PREMIUM 53,206 INCREASED LIMITS-EMPLOYER LIABILITY 2% 9812 1,064 TOTAL UNMODIFIED PREMIUM 54,270 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 (11,397) MODIFIED STANDARD PREMIUM 42,873 LOSS REIMBURSEMENT $250,000 9862 (22,064) UNDISCOUNTED PREMIUM 42,873 EXPENSE CONSTANT 0900 190 TOTAL ESTIMATED ANNUAL PREMIUM 20,999 ASSESSMENTS/TAXES 4.2% 0088 1,801 TOTAL DUE 22,800 - ---------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 MICHIGAN - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY SYNADYNE I JOBSITE ONLY DETROIT, MI 48073 CLERICAL OFFICE EMPLOYEES NOC 8810 5,385,600 0.30 16,157 LABOR WORLD OF AMERICA, INC. 3313 ROSCHESTER RD. ROYAL OAK, MI 48073 FLORISTS-CULTIVATING OR GARDENING- 0035 9,300 2.91 271 INCLUDING DRIVERS BAKERY & DRIVERS, ROUTE SUPERVISORS 2003 304,500 6.41 19,518 CARPET, RUG OR UPHOLSTERY CLEANING--SHOP 2585 8,200 8.92 731 - --AND SALESMEN DRIVERS CLEANING OR DYEING & ROUTE SUPERVISORS, 2586 70,100 3.98 2,790 SALESMEN, DRIVERS FURNITURE ASSEMBLING-WOOD-FROM 2881 5,160 3.27 169 MANUFACTURED PARTS TOOL MFG - NOT DROP OR 3113 1,659,600 4.16 69,039 MACHINE FORGED NOC AUTOMATIC SCREW MACHINE PRODUCTS 3145 17,800 4.71 838 MFG.- N.P.D. SKATE MFG 3146 33,200 6.02 1,999 ELECTRICAL APPARATUS MFG NOC 3179 5,500 4.26 234 SPRING MFG 3303 12,900 7.31 943 HEAT TREATING-METAL-N P D 3307 40,700 5.48 2,230 _________ OR COPPER GOODS MFG 3315 2,100 4.92 103 - --------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 MICHIGAN - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY WELDING OR CUTTING NOC & DRIVERS 3365 900 10.32 93 ELECTROPLATING NPD 3372 4,100 9.57 392 JEWELRY MFG 3383 150 3.22 5 METAL STAMPING MFG 3400 86,300 9.92 8,561 APPLICABLE TO MASS PRODUCTION MANUFACTURING OF STAMPED METAL ARTICLES INCLUDING, BUT NOT LIMITED TO, LICENSE PLATES, TAGS, TOYS, PIE PLATES, BUCKETS AND WASTE BASKETS. MINING OR ORE MILLING MACHINERY MFG 3507 11,400 8.26 942 P____TING MACHINE MFG. 3548 4,300 2.45 105 MACHINE SHOP NOC 3632 32,100 6.85 2,199 AUTOMOTIVE LIGHTING IGNITION OR STARTING 3648 1,200 6.09 73 APPARATUS MFG NOC RADIO APPARATUS MFG OR ASSEMBLY NOC 3681 23,000 3.45 794 INSTRUMENT MFG NOC 3685 19,800 2.45 485 GLASS MERCHANT 4130 11,900 8.24 981 BOX MFG - FOLDING PAPER - NOC 4243 6,400 6.33 405 PRINTING 4299 5,600 3.62 203 PLASTICS MFG: MOLDED PRODUCTS NOC 4484 10,900 6.91 753 METAL CEILING OR COVERAGE 5538 76,600 9.53 7,300 INSTALLATION & SHOP, DRIVERS CLEANER--DEBRIS REMOCAL 5610 78,800 6.42 5,059 CARPENTRY-DWELLINGS-THREE STORIES 5651 5,500 11.76 647 OR LESS _____ SUNDRIES MFG.N 0 C -NO CEREAL 6504 1,300 4.16 54 MILLING - -------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 MICHIGAN - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY CHAUFFERS & HELPERS NOC COMMERCIAL 7380 17,400 6.55 1,140 STORE: HARDWARE 8010 11,500 1.95 224 STORE: RETAIL NOC 8017 31,600 1.88 594 STORE: WHOLESALE NOC 8018 73,000 5.88 4,292 FURNITURE STORES--WHOLESALE OR RETAIL - 8044 18,900 3.03 573 DRIVERS BUILDING MATERIAL DEALER - NEW MATERIALS 8058 46,800 3.10 1,451 ONLY: STORE EMPLOYEES PLUMBERS' SUPPLIES DEALER & DRIVERS NPD 8111 7,800 4.30 335 ____STOCK DEALER - USED 8264 66,900 9.41 6,295 STORAGE WAREHOUSE NOC 8292 118,900 5.68 6,754 SALESPERSONS, COLLECTORS OR MESSENGERS - 8742 9,200 0.57 52 OUTSIDE ADDRESSING OR MAILING CO NPD 8800 116,900 2.89 3,378 CLERICAL OFFICE EMPLOYEES NOC 8810 920,000 0.30 2,760 BUILDING NOC-OPERATION BY OWNER OR 9015 11,600 5.60 650 LESSEE HOTEL: RESTAURANT EMPLOYEES 9058 2,000 2.58 52 PAINTING: SHOP ONLY & DRIVERS NPD 9501 30,500 6.63 2,022 - --------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 MICHIGAN - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY UNMODIFIED PREMIUM 174,645 INCREASED LIMITS-EMPLOYER LIABILITY 2% 9812 3,493 TOTAL UNMODIFIED PREMIUM 178,138 SCHEDULE MODIFICATION 25% 9887 (44,535) MODIFIED STANDARD PREMIUM 133,603 LOSS REIMBURSEMENT $250,000 9862 (73,461) UNDISCOUNTED PREMIUM 60,142 TOTAL ESTIMATED ANNUAL PREMIUM 60,142 TOTAL DUE 60,142 - -------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 MINNESOTA - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY SYNADYNE I JOBSITE ONLY PRINCETON, MN 55371 CLERICAL TELECOMMUTER EMPLOYEES. 8810 225,600 0.30 677 SUBJECT TO THE MINNESOTA STANDARD EXCEPTION MANUAL RULE. LABOR WORLD OF AMERICA, INC. JOBSITE ONLY MINNEAPOLIS, MN 55401 LANDSCAPE GARDENING & DRIVERS 0042 600 16.64 100 CODES 0042 AND 9102 PARK NOC MAY BE ASSIGNED TO THE SAME RISK.THE PAYROLL OF AN INDIVIDUAL EMPLOYEE MAY BE DIVIDED AND ALLOCATED BETWEEN CODES 0042 AND 9102 PROVIDED THAT THE ENTRIES ON THE ORIGINAL RECORDS OF THE INSURED DISCLOSE AN ALLOCATION OF EACH INDIVIDUAL'S PAYROLL.AN ESTIMATE OR PERCENTAGE ALLOCATION OF PAYROLL IS NOT PERMITTED. CLOTHING MFG. 2501 4,100 4.36 179 CARPENTRY SHOP ONLY AND DRIVERS 2802 5,200 4.64 241 CABINET WORKS - WITH POWER MACHINERY 2812 21,100 6.15 1,298 F1REPROOF EQUIPMENT MFG 3076 55,300 5.77 3,191 HEAT TREATING-METAL-N P D 3307 15,300 8.28 1,267 MACHINE SHOP NOC 3632 39,100 4.64 1,814 RADIO APPARATUS MFG OR ASSEMBLY NOC 3681 800 3.11 25 _______G - SET-UP PAPER 4240 900 4.84 44 PRINTING 4299 32,200 3.85 1,240 - ------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 MINNESOTA - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY BOOKBINDING 4307 106,100 3.46 3,671 PHOTOGRAPHER - ALL EMPLOYEES & CLERICAL, 4361 27,800 1.66 461 SALESPERSONS, DRIVERS. PAINT MFG 4558 8,250 4.87 402 DRUG MEDICINE OR PHARMACEUTICAL PREP. 4611 4,400 3.07 135 NO MFG. OF INGREDIENTS PHARMACEUTICAL OR SURGICAL GOODS MFG NOC 4693 1,600 2.10 34 SOAP OR SYNTHETIC DETERGENT MFG 4720 700 3.36 24 AUDIO OR VISUAL RECORDING MEDIA MFG 4923 11,100 2.84 315 INCLUDES TAPES OR DISKS, PHONOGRAPH RECORD MFG. TO BE SEPARATELY RATED AS CODE 4431. FURNITURE OR FIXTURES INSTALLATION 5146 7,600 7.54 573 PORTABLE - NOC PLUMBING NOC & DRIVERS 5183 1,800 10.63 191 PAINTING OR PAPER HANGING NOC & SHOP 5474 5,200 13.97 726 OPERATIONS, DRIVERS ALE OR BEER DEALER - WHOLESALE - & 7390 84,100 11.36 9,554 DRIVERS AUDIO OR CALL BOX SYSTEMS INSTALLATION 7605 500 1.70 9 WITHIN BUILDINGS FLORIST-STORE-DRIVERS 8001 1,200 2.60 31 STORE: RETAIL NOC 8017 111,300 2.12 2,360 STORE: WHOLESALE NOC 8018 34,600 5.16 1,785 HARDWARE STORES-RETAIL EXCLUSIVELY 8036 28,100 2.33 655 FURNITURE STORES --WHOLESALE OR RETAIL 8044 29,500 3.64 1,074 & DRIVERS - ------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 MINNESOTA - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY STORE: DRUG - WHOLESALE 8047 10,600 6.29 667 BUILDING MATERIAL DEALER - NEW MATERIALS 8232 1,500 6.96 104 ONLY: ALL OTHER EMPLOYEES & YARD, WAREHOUSE, DRIVERS STORAGE WAREHOUSE - FURNITURE - & 8293 700 19.00 133 DRIVERS DRAIN ELEVATOR OPERATION & LOCAL 8304 28,900 6.64 1,919 MANAGERS, DRIVERS CLERICAL TELECOMMUTER EMPLOYEES. 8810 105,000 0.30 315 SUBJECT TO THE MINNESOTA STANDARD _______TION MANUAL RULE. BUILDINGS-OPERATION BY CONTRACTORS 9014 68,200 6.53 4,453 HOSPITAL: ALL OTHER EMPLOYEES 9040 5,100 4.82 246 HOTEL - ALL EMPLOYEES & CLERICAL, 9052 118,600 3.18 3,771 SALESMEN, DRIVERS RESTAURANT NOC 9082 44,300 3.18 1,409 LAWN MAINTENANCE - COMMERCIAL 9102 2,750 4.91 135 OR DOMESTIC & DRIVERS CODES 9102 AND 0042, LANDSCAPE GARDENING AND DRIVERS MAY BE ASSIGNED TO THE SAME RISK. THE PAYROLL OF AN INDIVIDUAL EMPLOYEE MAY BE DIVIDED AND ALLOCATED BE- TWEEN CODES 0042 AND 9102 PROVIDED THAT THE ENTRIES ON THE ORIGINAL RECORDS OF THE INSURED DISCLOSE AN ALLOCATION OF EACH INDIVIDUAL'S PAYROLL. AN ESTIMATE OR PERCENTAGE ALLOCATION OF PAYROLL IS N0T PERMITTED. THEATRE NOC: ALL OTHER EMPLOYEES 9154 5,490 1.73 95 PAINTING OR LETTERING-INSIDE OF 9501 17,900 4.26 763 ___INGS-INCLUDING SHOP OPERATIONS DRIVERS-N P 0 WITH 9549 ADVERTISING - ---------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 MINNESOTA - ------------------- --------------- ----------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY COMPANIES OUTDOOR 3064 SIGN MFG OR 5474 PAINTING OR PAPER HANGING HOUSEHOLD APPLIANCES - ELECTRICAL 9519 2,100 4.49 94 INSTALLATION, SERVICE OR REPAIR DRIVERS. UNMODIFIED PREMIUM 46,180 INCREASED LIMITS-EMPLOYER LIABILITY 2% 9812 924 TOTAL UNMODIFIED PREMIUM 47,104 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 (9,892) SCHEDULE MODIFICATION 25% 9887 (9,303) MODIFIED STANDARD PREMIUM 27,909 LOSS REIMBURSEMENT $250,000 9862 (15,496) UNDISCOUNTED PREMIUM 27,909 TOTAL ESTIMATED ANNUAL PREMIUM 12,413 MINNESOTA SURCHARGE 8.7% 9135 2,428 TOTAL DUE 14,841 - --------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 MISSOURI - ------------------- -------------- ------------------------------ POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. OUTSOURCE INTERNATIONAL, INC. DEED ADDRESS ENTIRE STATE, MO 99999 CLERICAL OFFICE EMPLOYEES NOC 8810 44,000 0.41 180 UNMODIFIED 180 TOTAL UNMODIFIED PREMIUM 180 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 (38) MODIFIED STANDARD PREMIUM 142 LOSS REIMBURSEMENT $250,000 9862 (22) UNDISCOUNTED PREMIUM 142 TOTAL ESTIMATED ANNUAL PREMIUM 120 _____ COND INJURY FUND SURCHARGE 1.5% 0088 2 TOTAL DUE 122 - ---------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 MISSISSIPPI - ------------------- -------------- ------------------------------ POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. SYNADYNE I 6310 I-55 NORTH, STE 400 JACKSON, MS 39211 CLERICAL OFFICE EMPLOYEES NOC 8810 176,400 0.39 688 UNMODIFIED PREMIUM 688 INCREASED LIMITS-EMPLOYER LIABILITY 3.3% 9812 23 TOTAL UNMODIFIED PREMIUM 711 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 (149) MODIFIED STANDARD PREMIUM 562 LOSS REIMBURSEMENT $250,000 9862 (313) UNDISCOUNTED PREMIUM 249 TOTAL ESTIMATED ANNUAL PREMIUM 249 TOTAL DUE 249 - ------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 NORTH CAROLINA - ------------------- -------------- ------------------------------ POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. SYNADYNE I 8801 J.M. KEYNES DR., STE 300 CHARLOTTE, NC 28213 TRUCKING: MAIL, PARCEL OR PACKAGE 7231 33,700 5.60 1,887 DELIVERY-ALL EMPLOYEES & SALESPERSONS, DRIVERS SALESPERSONS, COLLECTORS OR MESSENGERS- 8742 34,200 0.86 294 OUTSIDE CLERICAL OFFICE EMPLOYEES NOC 8810 2,953,300 0.33 9,746 UNMODIFIED PREMIUM 11,927 INCREASED LIMITS-EMPLOYER LIABILITY 3.3% 9812 394 TOTAL UNMODIFIED PREMIUM 12,321 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 (2,587) MODIFIED STANDARD PREMIUM 9,734 LOSS REIMBURSEMENT $250,000 9862 (5,405) UNDISCOUNTED PREMIUM 4,329 TOTAL ESTIMATED ANNUAL PREMIUM 4,329 TOTAL DUE 4,329 - ------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 NEBRASKA - ------------------- -------------- ------------------------------ POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. OUTSOURCE INTERNATIONAL, INC. NEED ADDRESS ENTIRE STATE, NE 99999 COLD STORAGE LOCKER - FROZEN FOODS 8031 400 3.59 14 DEPARTMENT STORES - RETAIL 8039 111,100 1.39 1,544 FURNITURE STORES - WHOLESALE OR RETAIL - 8044 300 1.94 6 & DRIVERS BUILDING MATERIAL DEALER - NEW MATERIALS 8058 200 2.75 6 ONLY: STORE EMPLOYEES ______ MERCHANT 8102 200 4.23 8 OIL OR GAS WELL: SUPPLIES OR EQUIPMENT 8204 1,000 7.83 78 DEALER - USED - & LOCAL MANAGERS, DRIVERS BUILDING MATERIAL DEALER - NEW MATERIALS 8232 5,000 3.94 197 ONLY: ALL OTHER EMPLOYEES & YARD, WAREHOUSE, DRIVERS STORAGE WAREHOUSE NOC 8292 900 5.56 50 STORAGE WAREHOUSE - FURNITURE - & 8293 3,300 8.65 285 DRIVERS AUTOMOBILE CAR WASH AND DRIVERS 8380 700 3.10 22 SALESPERSONS, COLLECTORS OR MESSENGERS - 8742 20,700 0.68 141 OUTSIDE CLERICAL OFFICE EMPLOYEES NOC 8810 29,700 0.33 98 BUILDINGS-OPERATION BY CONTRACTORS 9014 45,200 3.70 1,672 BUILDINGS NOC-OPERATION BY OWNER OR 9015 700 3.03 21 LESSEE - ------------------------------------------------------------------------------------------------------ WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 NEBRASKA - ------------------- -------------- ------------------------------ POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. HOSPITAL: ALL OTHER EMPLOYEES 9040 55,900 2.44 1,364 HOTEL - ALL EMPLOYEES & SALESPERSON & 9052 9,700 2.93 284 DRIVERS HOTEL: RESTAURANT EMPLOYEES 9058 30 2.17 1 RESTAURANT NOC 9082 40,000 1.97 79 RELIGIOUS ORGANIZATION: 9101 5,700 3.20 182 ALL OTHER EMPLOYEES CEMETERY OPERATION & DRIVERS 9220 3,000 4.57 137 ______, GARBAGE OR REFUSE COLLECTION & 9403 9,700 10.04 974 DRIVERS UNMODIFIED PREMIUM 7,163 INCREASED LIMITS-EMPLOYER LIABILITY 3.3% 9812 236 TOTAL UNMODIFIED PREMIUM 7,399 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 (1,554) MODIFIED STANDARD PREMIUM 5,845 LOSS REIMBURSEMENT $250,000 9862 (894) UNDISCOUNTED PREMIUM 4,951 TOTAL ESTIMATED ANNUAL PREMIUM 4,951 TOTAL DUE 4,951 - ------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 NEW HAMPSHIRE - --------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. OUTSOURCE INTERNATIONAL, INC. NEED ADDRESS ENTIRE STATE, NH 99999 LANDSCAPE GARDENING & DRIVERS 0042 10,600 12.98 1,376 CODES 0042 AND 9102 PARK NOC MAY BE ASSIGNED TO THE SAME RISK. THE PAYROLL OF AN INDIVIDUAL EMPLOYEE MAY BE DIVIDED AND ALLOCATED BETWEEN CODES 0042 AND 9102 PROVIDED THAT THE ENTRIES ON THE ORIGINAL RECORDS OF THE INSURED DISCLOSE AN ALLOCATION OF EACH INDIVIDUAL'S PAYROLL. AN ESTIMATE OR PERCENTAGE ALLOCATION OF PAYROLL IS NOT PERMITTED. CEMENT MFG 1701 1,600 8.69 139 ICE CREAM MFG. & SALESMEN, DRIVERS 2039 23,200 8.12 1,884 MEAT PRODUCTS MFG NOC 2095 100 14.24 14 SAW MILL 2710 700 13.85 97 BOX, BOX SHOOK OR PALLET MFG 2759 16,800 17.44 2,930 WOODEN FURNITURE ASSEMBLING-WOOD-FROM 2881 29,100 10.05 2,925 MANUFACTURED PARTS PHONOGRAPH CABINET MFG 2883 49,800 8.22 4,094 SHEET METAL WORK - SHOP 3066 8,600 7.45 641 SCREW MFG 3145 34,900 4.47 1,560 CAN MFG 3220 300 5.27 16 ARMS MFG NOC 3548 4,500 2.29 103 _______ SHOP NOC 3632 3,000 4.60 138 RADIO APPARATUS MFG OR ASSEMBLY NOC 3681 37,400 3.86 1,444 - ------------------------------------------------------------------------------------------------------------------------ WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 NEW HAMPSHIRE - --------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. INSTRUMENT MFG NOC 3685 3,000 4.80 144 BOX MFG - FOLDING PAPER - NOC 4243 25,300 4.64 1,174 CORRUGATED OR FIBER BOARD CONTAINER 4244 200 4.68 9 MFG BOOKBINDING 4307 1,500 6.83 102 BONE OR IVORY GOODS MFG 4452 16,700 7.81 1,304 PLASTICS MFG: MOLDED PRODUCTS NOC 4484 50,400 7.61 3,835 FABRIC COATING OR IMPREGNATING 4493 126,300 6.50 8,210 PAINT MFG 4558 19,000 4.20 798 _______ MEDICINE OR PHARMACEUTICAL 4611 22,300 4.63 1,032 PREP __ MFG. OF INGREDIENTS FURNITURE OR FIXTURES INSTALLATION - 5146 4,200 12,27 515 PORTABLE - NOC PLUMBING NOC & DRIVERS 5183 600 9.17 55 UNITING - NOT CHIMNEYS - ALL 5213 81,800 40.57 33,186 OPERATIONS CONCRETE OR CEMENT WORK - FLOORS, 5221 900 12.86 166 DRIVEWAYS, YARDS OR SIDEWALKS - & DRIVERS FENCE ERECTION - WOOD NOC 5403 284,000 19.52 55,437 _LAZIER - AWAY FROM SHOP - & DRIVERS 5462 100 17.30 17 PAINTING OR PAPER HANGING NOC & SHOP 5474 2,000 17.96 359 OPERATIONS, DRIVERS STREET OR ROAD CONSTRUCTION OR 5506 400 15.68 63 RECONSTRUCTION & DRIVERS _ILLING OR GRADING TUNNELING BRIDGE OR CULVERT BUILDING QUARRYING STONE _______ TO BE SEPARATELY RATED _______ OR GRADING TUNNELING BRIDGE OR CULVERY BUILDING QUARRYING STONE - ------------------------------------------------------------------------------------------------------------------------ WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 NEW HAMPSHIRE - --------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. CRUSHING TO BE SEPARATELY RATED TIMEKEEPERS-CONSTRUCTION OR ERECTION 5610 28,400 19.48 5,532 SEWER CONSTRUCTION - ALL OPERATIONS & 6306 1,280 7.65 98 DRIVERS FOOD SUNDRIES MFG.N O C -NO CEREAL 6504 209,500 9.13 19,127 MILLING TRUCKING: PARCEL OR PACKAGE DELIVERY-ALL 7230 300 9.60 29 EMPLOYEES & DRIVERS REFRIGERATOR CAR LOADING OR UNLOADING 7360 4,000 14.39 576 LIMOUSINE COMPANY - ALL OTHER EMPLOYEES 7370 100 11.10 11 ______VERS & NON-SCHEDULED CHAUFFEURS & HELPERS NOC COMMERCIAL 7380 48,400 9.15 4,429 ALE OR BEER DEALER - WHOLESALE - & 7390 8,400 7.09 596 DRIVERS GARBAGE WORKS 7590 100 10.13 10 STORE: HARDWARE 8010 2,000 2.49 50 STORE GROCERY WHOLESALE 8018 78,500 9,48 7,442 FURNITURE STORES -- WHOLESALE OR RETAIL - 8044 3,000 6.99 210 & DRIVERS BUILDING MATERIAL DEALER - NEW MATERIALS 8232 9,400 6.54 615 ONLY: ALL OTHER EMPLOYEES & YARD, WAREHOUSE, DRIVERS RUBBER STOCK DEALER - USED - AND 8264 114,200 10.73 12,254 DRIVERS NPD STORAGE WAREHOUSE NOC 8292 2,400 9.95 239 STORAGE WAREHOUSE - FURNITURE - & 8293 5,500 23.44 1,289 DRIVERS - ------------------------------------------------------------------------------------------------------------------------ WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 NEW HAMPSHIRE - --------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. AUTOMOBILE CAR WASH AND DRIVERS 8380 900 5.49 49 SALESPERSONS, COLLECTORS OR 8742 8,700 1.04 90 MESSENGERS - OUTSIDE CLERICAL OFFICE EMPLOYEES NOC 8810 335,400 0.56 1,878 BUILDINGS-OPERATION BY CONTRACTORS 9014 1,600 9.50 152 BUILDINGS NOC-OPERATION BY OWNER OR 9015 1,000 8.02 80 LESSEE RELIGIOUS ORGANIZATION: 9101 3,900 4.92 192 ALL OTHER EMPLOYEES LAWN MAINTENANCE - COMMERCIAL OR 9102 45,000 8.07 3,632 ____IC & DRIVERS CODES 9102 AND 0042, LANDSCAPE GARDENING AND DRIVERS MAY BE ASSIGNED TO THE SAME RISK. THE PAYROLL OF AN INDIVIDUAL EMPLOYEE MAY BE DIVIDED AND ALLOCATED BETWEEN CODES 0042 AND 9102 PROVIDED THAT THE ENTRIES ON THE ORIGINAL RECORDS OF THE INSURED DISCLOSE AN ALLOCATION OF EACH INDIVIDUAL'S PAYROLL. AN ESTIMATE OR PERCENTAGE ALLOCATION OF PAYROLL IS NOT PERMITTED. THEATRE NOC: OTHER EMPLOYEES 9154 200 2.69 5 PAINTING: SHOP ONLY & DRIVERS NPD 9501 6,900 6.73 464 UNMODIFIED PREMIUM 182,766 INCREASED LIMITS - EMPLOYER 3.3% 9812 6,031 TOTAL UNMODIFIED PREMIUM 188,797 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 (39,647) MODIFIED STANDARD PREMIUM 149,150 - ------------------------------------------------------------------------------------------------------------------------ WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 NEW HAMPSHIRE - --------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. LOSS REIMBURSEMENT $250,000 9862 (82,809) UNDISCOUNTED PREMIUM 66,341 TOTAL ESTIMATED ANNUAL PREMIUM 66,341 TOTAL DUE 66,341 - ------------------------------------------------------------------------------------------------------------------------ WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 NEW JERSEY - --------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. LABOR WORLD OF AMERICA, INC. 301 NORTH ALMONESSON RD. DEPTFORD, NJ 08096 STORE: RETAIL-N.O.C. 8017 180,000 2.75 4,950 CLERICAL OFFICE EMPLOYEES N.O.C. 8810 56,500 0.33 186 UNMODIFIED PREMIUM 5,136 TOTAL UNMODIFIED PREMIUM 5,136 MODIFIED STANDARD PREMIUM 5,136 LOSS REIMBURSEMENT $250,000 9862 (2,331) UNDISCOUNTED PREMIUM 5,136 TOTAL ESTIMATED ANNUAL PREMIUM 2,805 _______ 5% 0935 257 _______ .2% 0936 10 ESTIMATED TOTAL DUE 3,072 - ------------------------------------------------------------------------------------------------------------------------ WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 NEW MEXICO - --------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. SYNADYNE I JOBSITE ONLY ABUELO, NM 87732 LANDSCAPE GARDENING & DRIVERS 0042 10,000 16.31 1,631 CEMENT MFG 1701 7,700 4.38 337 BAKERY & DRIVERS, ROUTE SUPERVISORS 2003 94,800 7.41 7,025 MILK DEPOT OR MILK DEALER & ROUTE 2070 40 9.17 4 SUPERVISORS, SALESMEN, DRIVERS BOTTLING NOC & ROUTE SUPERVISORS, 2157 42,300 8.40 3,553 DRIVERS RUG, CARPET OR UPHOLSTERY CLEANING 2585 400 8.57 34 DRY CLEANING AND LAUNDRY STORE - RETAIL 2589 700 5.03 35 - - & ROUTE SUPERVISORS, SALESMEN, DRIVERS PLANING OR MOLDING MILL 2731 4,400 8.07 355 FURNITURE ASSEMBLING-WOOD-FROM 2881 9,400 6.03 567 MANUFACTURED PARTS PHONOGRAPH CABINET MFG 2883 900 7.32 66 ELECTROPLATING NPD 3372 3,700 8.83 327 METAL STAMPING MFG 3400 700 6.36 45 APPLICABLE TO MASS PRODUCTION MANUFACTURING OF STAMPED METAL ARTICLES INCLUDING, BUT NOT LIMITED TO, LICENSE PLATES, TAGS, TOYS, PIE PLATES, BUCKETS AND WASTE BASKETS. ___ MFG NOC 3548 900 3.52 32 ______ MAKING 3620 43,600 9.36 4,081 MACHINE SHOP NOC 3632 4,600 7.00 322 - ------------------------------------------------------------------------------------------------------------------------ WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 NEW MEXICO - --------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. ELECTRICAL APPARATUS INSTALLATION OR 3724 2,200 14.92 328 REPAIR & DRIVERS PAPER GOODS MFG NOC 4279 5,700 9.90 564 PRINTING 4299 3,500 3.28 115 BONE OR IVORY GOODS MFG 4452 2,000 6.34 127 PLASTICS MFG: SHEET RODS OR TUBES 4459 1,700 8.34 142 ASSAYING-NPD 4511 10,100 1.85 187 ERECTION - METAL BRIDGES 5040 100 44.64 45 FURNITURE OR FIXTURES INSTALLATION - 5146 7,900 7.13 563 _______ - NOC PLUMBING NOC & DRIVERS 5183 16,300 8.06 1,314 ELECTRICAL WIRING - WITHIN BUILDINGS 5190 200 5.31 11 & DRIVERS. CONCRETE OR CEMENT WORK - FLOORS, 5221 4,400 15.51 682 DRIVEWAYS, YARDS OR SIDEWALKS - & DRIVERS FENCE ERECTION - WOOD NOC 5403 47,000 17.95 8,437 METAL CEILING OR WALL COVERING 5538 600 9.54 57 INSTALLATION & SHOP, DRIVERS TIMEKEEPERS-CONSTRUCTION OR 5610 16,600 8.82 1,464 ERECTION GRADING OF LAND NOC & DRIVERS 6217 2,300 8.75 201 CHAUFFEURS & HELPERS NOC COMMERCIAL 7380 9,500 8.15 774 BURGLER ALARM INSTALLATION OR REPAIR 7605 700 4.42 31 DRIVERS STORE: HARDWARE 8010 18,000 2.82 508 STORE: RETAIL NOC 8017 14,200 2.89 410 - ------------------------------------------------------------------------------------------------------------------------ WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 NEW MEXICO - ------------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. STORE GROCERY WHOLESALE 8018 40,200 7.20 2,894 STORE: MEAT, FISH OR POULTRY DEALER - 8021 1,100 13.91 153 WHOLESALE FURNITURE STORES -- WHOLESALES OR RETAIL - 8044 34,900 4.23 1,476 & DRIVERS BUILDING MATERIAL DEALER - NEW MATERIALS 8058 12,500 3.73 466 ONLY: STORE EMPLOYEES METAL MERCHANT & DRIVERS 8106 31,100 9.67 3,007 APPLIES TO DEALERS OF IRON, STEEL OR NONFERROUS METAL. MACHINERY DEALER NOC - STORE OR YARD - 8107 5,700 6.54 373 & DRIVERS PLUMBERS' SUPPLIES DEALER & DRIVERS NPD 8111 5,800 6.30 365 CONTRACTOR'S PERMANENT YARD 8227 3,300 5.65 186 BUILDING MATERIAL DEALER - NEW MATERIALS 8232 2,600 11.07 288 ONLY: ALL OTHER EMPLOYEES & YARD, WAREHOUSE, DRIVERS STORAGE WAREHOUSE NOC 8292 100 7.69 8 STORAGE WAREHOUSE - FURNITURE - & 8293 400 16.57 66 DRIVERS AUTOMOBILE CAR WASH AND DRIVERS 8380 19,200 4.08 783 ARCHITECT OR ENGINEER - CONSULTING NPD 8601 4,600 1.49 69 SALESPERSONS, COLLECTORS OR MESSENGERS - 8742 39,000 1.02 398 OUTSIDE CLERICAL OFFICE EMPLOYEES NOC 8810 1,100,300 0.49 5,391 _________ - VETERINARY - & DRIVERS 8831 2,200 2.44 54 - --------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 NEW MEXICO - ------------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. HOTEL - ALL EMPLOYEES & SALESPERSON & 9052 100 7.28 7 DRIVERS SEWER CLEANING & DRIVERS 9402 1,100 8.25 91 ASHES, GARBAGE OR REFUSE COLLECTION & 9403 4,000 11.19 448 DRIVERS CARPET INSTALLATION 9521 1,000 8.86 89 SIGN MFG - ERECTION, REPAIR OR 9552 50 13.35 7 MAINTENANCE - & SHOP, DRIVERS UNMODIFIED PREMIUM 50,993 INCREASED LIMITS - EMPLOYER LIABILITY 3.3% 9812 1,683 TOTAL UNMODIFIED PREMIUM 52,676 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 (11,062) SCHEDULE MODIFICATION 25% 9887 (10,404) MODIFIED STANDARD PREMIUM 31,210 LOSS REIMBURSEMENT $250,000 9862 (17,329) UNDISCOUNTED PREMIUM 13,881 TOTAL ESTIMATED ANNUAL PREMIUM 13,881 NEW MEXICO FILING FEE 5 0088 5 TOTAL DUE 13,886 - ---------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 NEW YORK - ------------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. OUTSOURCE INTERNATIONAL, INC. NEED ADDRESS ENTIRE STATE, NY 99999 STORES RETAIL STORES N O C - NO SERVICE OF 8017 289,800 2.61 7,564 FOOD CLERICAL OFFICE EMPLOYEES NOC 8810 1,400 0.44 6 UNMODIFIED PREMIUM 7,570 TOTAL UNMODIFIED PREMIUM 7,570 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 (1,590) MODIFIED STANDARD PREMIUM 5,980 LOSS REIMBURSEMENT $250,000 9862 (3,075) ______ COUNTED PREMIUM 5,980 TOTAL ESTIMATED ANNUAL PREMIUM 2,905 NEW YORK STATE ASSESSMENT 13.9% 9704 831 TOTAL DUE 3,736 - --------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 PENNSYLVANIA - ------------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. OUTSOURCE INTERNATIONAL, INC. JOBSITE ONLY PITTSBURGH, PA 15201 CLERICAL OFFICE EMPLOYEES 0953 528,100 0.49 2,588 SYNADYNE I 10500 ROOSEVELT BLVD. PHILADELPHIA, PA 19116 CLERICAL OFFICE EMPLOYEES 0953 489,600 0.49 2,399 WORLD OF AMERICA, INC. 720 EAST JOHNSON HWY. NORRISTOWN, PA 19401 CONTRACT GARDENERS NURSERYMEN AND 0013 1,600 9.48 152 LANDSCAPE CONTRACTORS ALL EMPLOYEES EXCEPT OFFICE NPD BAKERIES-INCLUDING STORE - ALL EMPLOYEES 0105 39,000 9.77 3,810 EXCEPT OFFICE PRESERVING OR CANNING OF FOOD 0113 8,500 6.70 570 LAUNDRIES INCLUDING DYEING AND CLEANING 0141 33,400 12.45 4,158 AND INCLUDING RECEIVING STATIONS-ALL EMPLOYEES EXCEPT OFFICE PLASTICS ARTICLES MFG INJECTION MOLDING 0221 469,600 9.03 42,405 NPD WITH CLASS 222 AT THE SAME OR CONTIGOUS LOCATIONS PLASTICS ARTICLES MFG N.O.C. 0222 500 8.69 43 PAPER BOX AND CONTAINER MFG INCLUDING 0257 63,300 10.65 6,741 __________ PAPER BAGS MAILING TUBES FILE JACKETS WALLETS AND PAPER DISHES - ---------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 PENNSYLVANIA - ------------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. PRINTING - INCLUDING INCIDENTAL ENGRAV- 0281 196,500 6.27 12,321 ING, AND THE ASSEMBLY, STAPLING OR BIND- ING OF CIRCULARS PAMPHLETS OR CATALOGUES NEWSPAPER AND PERIODICAL PRINTING OR 0282 6,100 8.93 545 PUBLISHING. CARPENTRY SHOP, INCLUDING PLANING MILL. 0305 12,000 11.36 1,363 CABINET WORKS WITH POWER 0311 1,400 7.06 99 DRIVEN MACHINERY ROLLING, DRAWING OR EXTRUDING OF NON- 0403 9,400 8.66 814 FERROUS METALS ALSO INCLUDES MAKING NON-FERROUS PIP OR TUBES OR FORGING NON-FERROUS METALS _______ MFG AXES AGRICULTURAL AND GARDENING 0433 2,500 11.28 282 TOOLS SLEDGEHAMMERS LOGGING TOOLS CONSTRUCTION TOOLS WHEELBARROWS AND OIL WELL TOOLS HARDWARE MFG N O C INCLUDING FOUNDRY 0445 36,200 7.73 2,798 BUILDERS HARDWARE GAS AND ELECTRIC FIXTURES MEAT CHOPPERS COFFEE GRINDERS SADIRONS AND PLUMBERS FITTINGS ELECTROPLATING 0449 1,700 7.58 129 SHEET METAL WORK SHOP ONLY 0454 21,600 9.31 2,011 WIRE GOODS MFG N P D 0457 350 9.12 32 EYELET, NEEDLE PIN PEN AND TACK MFG. 0459 1,900 2.87 55 MACHINE SHOPS--NO WOODWORKING--NO BOILER 0461 4,900 6.98 342 MAKING ELECTRICAL APPARATUS MFG-NO IRON OR 0473 2,600 4.01 104 STEEL FOUNDRY INSTRUMENT MFG PROFESSIONAL OR 0487 157,400 1.82 2,865 ______TIFIC - ---------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 PENNSYLVANIA - ------------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. EMPLOYMENT CONTACTOR - TEMPORARY STAFF - 0544 33,200 21.47 7,128 MANUFACTURING OR LIGHT INDUSRTIAL OPERATIONS, N.O.C. PAINT AND COLORS MFG-NO RED OR WHITE 0563 22,900 6.15 1,408 LEAD MFG WALLBOARD INSTALLATION--WITHIN BUILDINGS 0645 2,600 13.71 356 INCLUDES THE ENTIRE OPERATION OF IN- STALLING DRYWALL/WALLBOARD INCLUDING TAPING, SEAMING, TEXTURING, BUT NOT PAINTING FURNITURE OR FIXTURE INSTALLATION - 0646 11,700 11.06 1,294 PORTABLE - IN OFFICES OR STORES _____TICAL INSULATION MATERIAL 0647 300 19.78 59 INSTALLATION CARPENTRY--INSTALLATION OF CABINET WORK, 0648 5,300 8.02 425 FINISHED WOODEN FLOORING OR INTERIOR TRIM BOARDING UP OF ABANDONED BUILDINGS 0651 6,200 17.63 1,093 CARPENTRY - DETACHED DWELLINGS 0652 1,300 13.47 175 CONCRETE CONSTRUCTION 0654 14,000 25.01 3,501 MACHINERY OR EQUIPMENT ERECTION OR 0675 11,900 11.89 1,415 REPAIR PUBLIC WEIGHERS AND SAMPLERS STEAMSHIP 0709 14,300 4.50 644 AGENCIES ALL EMPLOYEES EXCEPT OFFICE AND SALESMEN FURNITURE MOVING AND/OR STORAGE. 0806 14,200 25.63 3,639 TRUCKMEN-ALL EMPLOYEES EXCEPT OFFICE 0811 1,900 18.92 359 STORAGE ALL EMPLOYEES EXCEPT OFFICE 0813 12,100 14.66 1,774 STORAGE DISTRIBUTORS, WHOLESALE 0821 3,500 14.55 509 - ---------------------------------------------------------------------------------------------------------------------- WC7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 PENNSYLVANIA - ------------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. DEALERS IN CLOTH CLIPPING WIPING RAGS 0862 47,000 12.94 6,082 OLD RAGS AND PAPER FOR PAPER STOCK AND DEALERS IN SECONDHAND BOTTLES AND RUBBER STOCK-NO DEALING IN METALS OR BUILDING MATERIALS, BUT INCLUDING BEVERAGE CAN RE- CYCLING DEALERS IN CLOTH CLIPPINGS, NEW GOODS ONLY, MUST BE REFERED TO THE BUREAU FOR CLASSIFICATION AND RATING MEAT, FISH AND/OR POULTRY STORE- 0915 9,600 5.40 518 RETAIL, ALL EMPLOYEES EXCEPT OFFICE DRY GOODS AND CLOTHING STORES WHOLESALE 0916 2,900 3.36 97 OR RETAIL ALL EMPLOYEES INCLUDING OFFICE BAKERY SHOP--RETAIL, INCLUDING ON-SITE 0918 22,800 6.23 1,420 PREPARATION, INCLUDING OFFICE. APPLIES TO RISKS PRODUCING BAKERY PRO- DUCTS AND RISKS WHO BUY FINISHED BAKERY PRODUCTS FROM UNRELATED PRODUCERS. SALES ARE OVER THE COUNTER FOR PERSONAL OR HOUSEHOLD CONSUMPTION, EITHER ON PREMISES OR THROUGH SATELLITE OUTLETS. FLORIST STORE - RETAIL OR WHOLESALE 0919 1,100 4.02 44 FURNITURE STORE - RETAIL OR WHOLESALE 0922 166,000 7.08 11,753 NO WOODWORKING WHOLESALE STORES N O C 0924 23,300 9.94 2,316 HARDWARE STORES - WHOLESALE 0926 41,000 5.93 2,431 RETAIL STORES N O C-ALL EMPLOYEES 0928 307,200 4.09 12,564 INCLUDING OFFICE EMPLOYMENT CONTRACTOR-TEMPORARY STAFF - 0929 163,300 10.99 17,947 MERCHANTILE OPERATIONS VENDING OR COIN OPERATED 0933 5,900 6.99 412 MACHINES - ---------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 PENNSYLVANIA - ------------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. AUTO PARTS DEALER - WHOLESALE 0934 259,800 4.88 12,678 EMPLOYMENT CONTRACTOR-TEMPORARY STAFF - 0937 5,500 30.45 1,675 HEAVY SERVICE. CLUB - COUNTRY, GOLF, OR YACHTING - ALL 0944 14,100 4.77 673 EMPLOYEES EXCEPT OFFICE. HOTEL RESTAURANT EMPLOYEES, ALL EMPLOY- 0945 13,100 6.01 787 EES EXCEPT OFFICE. EMPLOYMENT CONTRACTOR-TEMPORARY STAFF - 0947 50,900 12.70 6,464 MAINTENANCE OR SERVICE. MAILING OR ADDRESSING COMPANY - ALL 0948 19,500 1.14 222 EMPLOYEES INCLUDING OFFICE ____ETING SERVICE -- TEMPORARY HELP 0949 40,600 1.84 747 SALESPERSON - OUTSIDE 0951 103,100 1.03 1,062 OFFICE MACHINE SERVICE OR REPAIR. 0952 400 1.83 7 CLERICAL OFFICE EMPLOYEES 0953 268,000 0.49 1,313 ENGINEER, CONSULTING -- MECHANICAL, 0955 23,500 1.06 249 CIVIL, ELECTRICAL OR MINING ENGINEERS, OR ARCHITECTS. COLLEGES AND SCHOOLS ALL EMPLOYEES 0965 7,400 1.09 81 INCLUDING OFFICE EXCEPT PURNELL ACT EMPLOYEES AMUSEMENTS OUTDOOR FAIRS EXHIBITIONS 0969 3,500 7.37 258 HORSE SHOWS AND AMUSEMENT PARKS N P D ALL EMPLOYEES EXCEPT OFFICE INCLUDING TICKET SELLERS AND TICKET COLLECTORS BUT EXCLUDING ORGANIZED ATHLETICS APARTMENT HOUSE -- OPERATED BY OWNER, 0971 188,500 9.53 17,964 LESSEE OR MANAGEMENT AGENCY ____S-ALL OTHER EMPLOYEES, EXCEPT 0973 4,250 8.04 342 OFFICE. - --------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 PENNSYLVANIA - ------------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. RESTAURANTS AND CLUBS-ALL EMPLOYEES 0975 200 5.19 10 INCLUDING OFFICE SANITARY COMPANY (SEPTIC TANK, CESSPOOL 0992 5,000 8.85 443 OR CHEMICAL PORTABLE TOILET CLEANING) CEMETERIES-ALL EMPLOYEES EXCEPT OFFICE 0999 7,000 13.62 953 AND SALESMEN UNMODIFIED PREMIUM 211,917 INCREASED LIMITS-EMPLOYER LIABILITY 3.3% 9812 6,993 TOTAL UNMODIFIED PREMIUM 218,910 MODIFIED STANDARD PREMIUM 218,910 LOSS REIMBURSEMENT $250,000 9862 (121,539) UNDISCOUNTED PREMIUM 97,371 TOTAL ESTIMATED ANNUAL PREMIUM 97,371 TOTAL DUE 97,371 - ----------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 SOUTH CAROLINA - ------------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. SYNADYNE I JOBSITE ONLY ABBEVILLE, SC 29620 CLERICAL OFFICE EMPLOYEES 8810 886,000 0.28 2,481 BUILDINGS NOC-OPERATION BY OWNER OR 9015 40,500 4.01 1,624 LESSEE UNMODIFIED PREMIUM 4,105 INCREASED LIMITS-EMPLOYER LIABILITY 3.3% 9812 135 TOTAL UNMODIFIED PREMIUM 4,240 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 (890) SCHEDULE MODIFICATION 25% 9887 (838) MODIFIED STANDARD PREMIUM 2,512 LOSS REIMBURSEMENT $250,000 9862 (1,435) UNDISCOUNTED PREMIUM 1,077 TOTAL ESTIMATED ANNUAL PREMIUM 1,077 TOTAL DUE 1,077 - -------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 SOUTH DAKOTA - ------------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. OUTSOURCE INTERNATIONAL, INC. NEED ADDRESS ENTIRE STATE, SD 99999 CLERICAL OFFICE EMPLOYEES NOC 8810 14,700 0.45 66 UNMODIFIED PREMIUM 66 INCREASED LIMITS-EMPLOYER LIABILITY 3.3% 9812 2 TOTAL MODIFIED PREMIUM 68 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 (14) MODIFIED STANDARD PREMIUM 54 LOSS REIMBURSEMENT $250,000 9862 (29) UNDISCOUNTED PREMIUM 25 TOTAL ESTIMATED ANNUAL PREMIUM 25 SOUTH DAKOTA POLICY FEE 0088 14 TOTAL DUE 39 - --------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 TENNESSEE - ------------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. SYNADYNE I 151 LAFAYETTE STREET NASHVILLE, TN 37210 CLERICAL OFFICE EMPLOYEES NOC 8810 1,049,700 0.38 3,989 LABOR WORLD OF AMERICA, INC. JOBSITE ONLY KNOXVILLE, TN 37901 BOTTLING NOC & ROUTE SUPERVISORS, 2157 1,500 5.54 83 DRIVERS ____NING OR DYEING & ROUTE SUPERVISORS, 2586 500 3.20 16 SALESMEN, DRIVERS DRY CLEANING AND LAUNDRY STORE - RETAIL 2589 300 3.35 10 & ROUTE SUPERVISORS, SALESMEN, DRIVERS SHEET METAL WORK - SHOP 3066 27,100 7.18 1,946 TOOL MFG - NOT DROP OR MACHINE FORGED - 3113 134,000 2.94 3,940 NOC BUTTON OR FASTENER MFG - METAL 3131 23,000 3.92 902 MACHINERY OR EQUIPMENT ERECTION OR 3724 4,700 10.75 505 REPAIR NOC & DRIVERS PAPER MFG 4239 160,300 2.37 3,799 BOX MFG - FOLDING PAPER - NOC 4243 2,100 5.35 112 PLUMBING NOC & DRIVERS 5183 1,200 6.97 84 CONCRETE OR CEMENT WORK - FLOORS, 5221 2,400 8.76 210 DRIVEWAYS, YARDS OR SIDEWALKS - & DRIVERS CARPENTRY NOC 5403 33,300 13.66 4,549 - ---------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 TENNESSEE - ------------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. CARPENTRY-INSTALLATION OF CABINET WORK 5437 1,500 7.80 117 OR INTERIOR TRIM SHEET ROCK INSTALLATION - WITHIN 5445 9,000 13.95 1,256 BUILDINGS - & DRIVERS PAINTING OR PAPER HANGING NOC & SHOP 5474 1,500 13.14 197 OPERATIONS, DRIVERS INSULATION WORK NOC & DRIVERS 5479 120 17.91 21 FOOD SUNDRIES MFG. NOC - NO CEREAL 6504 126,100 4.49 5,662 MILLING METAL MERCHANT & DRIVERS 8106 5,300 7.23 383 APPLIES TO DEALERS OF IRON, STEEL OR FERROUS METAL. SALESPERSONS, COLLECTORS OR MESSENGERS - 8742 215,500 0.83 1,789 OUTSIDE CLERICAL OFFICE EMPLOYEES NOC 8810 1,041,400 0.38 3,957 BUILDINGS-OPERATION BY CONTRACTORS 9014 100,300 5.95 5,968 BUILDINGS NOC-OPERATION BY OWNER OR 9015 50,600 5.86 2,965 LESSEE HOTEL - ALL EMPLOYEES & SALESPERSON & 9052 280,500 4.87 13,660 DRIVERS HOTEL: RESTAURANT EMPLOYEES 9058 51,500 3.52 1,813 JOBSITE ONLY NASHVILLE, TN 37201 FARM: NURSERY EMPLOYEES & DRIVERS 0005 150 7.27 11 INCLUDES INCIDENTAL LANDSCAPE GARDENING FARM: VEGETABLE & DRIVERS 0008 17,200 4.20 722 ORCHARD & DRIVERS 0016 9,300 8.10 753 - ---------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 TENNESSEE - ------------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. HATCHERIES NO FARMING OPERATIONS 0034 4,600 7.60 350 INCLUDING DRIVERS LANDSCAPE GARDENING & DRIVERS 0042 57,400 10.14 5,820 CODES 0042 AND 9102 PARK NOC MAY BE ASSIGNED TO THE SAME RISK. THE PAYROLL OF AN INDIVIDUAL EMPLOYEE MAY BE DIVIDED AND ALLOCATED BETWEEN CODES 0042 AND 9102 PROVIDED THAT THE ENTRIES ON THE ORIGINAL RECORDS OF THE INSURED DISCLOSE AN ALLOCATION OF EACH INDIVIDUAL'S PAYROLL. AN ESTIMATE OR PERCENTAGE ALLOCATION OF PAYROLL IS NOT PERMITTED. DOMESTIC SERVICE CONTRACTOR - INSIDE 0917 52,000 5.47 2,844 _____RY & DRIVERS 2121 30,500 3.60 1,098 __CE MFG 2150 4,000 12.79 512 ___ET MFG 2380 1,000 3.42 34 CARPET OR RUG MFG NOC 2402 2,500 4.71 118 TEXTILE - BLEACHING, DYEING 2413 17,800 9.64 1,716 MERCERIZING, FINISHING YARN OR THREAD DYEING OR FINISHING NPD 2416 22,100 6.03 1,333 CLOTHING MFG. 2501 21,500 4.60 989 LAUNDRY NOC & ROUTE SUPERVISORS, 2585 30,800 6.11 1,882 SALESMEN, DRIVERS FURNITURE STOCK MFG. 2735 300 9.21 28 BOX, BOX SHOOK OR PALLET MFG 2759 2,100 11.31 238 WOODEN CARPENTRY SHOP ONLY AND DRIVERS 2802 900 8.93 80 ____TURE ASSEMBLING-WOOD-FROM 2881 150 5.56 8 MAUNFACTURED PARTS - ---------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 TENNESSEE - ------------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. IRON OR STEEL: MANUFACTURING 3018 4,500 7.68 346 ROLLING MILL NOC & DRIVERS IRON WORKS - SHOP - ORNAMENTAL 3040 12,200 7.47 911 STOVE MFG 3169 22,700 9.06 2,057 ENAMEL OR AGATE WARE MFG. 3224 42,400 6.81 2,887 TACK MFG. 3270 36,000 3.45 1,242 WELDING OR CUTTING NOC & DRIVERS 3365 150 14.79 22 METAL STAMPING MFG 3400 9,000 7.51 676 APPLICABLE TO MASS PRIDUCTION MANUFACTURING OF STAMPED METAL ARTICLES INCLUDING, BUT NOT LIMITED TO, LICENSE PLATES, TAGS, TOYS, PIE PLATES, BUCKETS AND WASTE BASKETS. AGRICULTURAL OR CONSTRUCTION MACHINERY 3507 69,400 5.62 3,900 MFG ARMS MFG NOC 3548 3,000 3.12 94 MACHINE SHOP NOC 3632 22,100 5.99 1,324 CONCRETE PRODUCTS MFG & DRIVERS 4034 5,600 11.66 653 PLASTER BOARD OR PLASTER BLOCK MFG & 4036 103,000 4.53 4,666 DRIVERS LOOSE-LEAF LEDGER OR NOTE BOOK MFG 4251 400 3.81 15 PAPER GOODS MFG NOC 4279 7,350 3.86 284 PRINTING 4299 112,000 3.03 3,394 RUBBER GOODS MFG NOC 4410 1,500 5.69 85 PLASTICS MFG: SHEETS RODS OR TUBES 4459 600 4.19 25 PLASTICS MFG: MOLDED PRODUCTS NOC 4484 53,800 6.16 3,314 - ----------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 TENNESSEE - ------------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. MASONRY NOC 5022 13,300 13.10 1,742 AWNING, TENT OR CANVAS GOODS ERECTION 5102 132,400 11.92 15,782 REMOVAL OR REPAIR & DRIVERS FURNITURE OR FIXTURES INSTALLATION - 5146 106,400 8.30 8,831 PORTABLE - NOC CONCRETE WORK-INCIDENTAL TO THE 5215 7,900 8.19 647 CONSTRUCTION OF PRIVATE RESIDENCE STREET OR ROAD CONSTRUCTION OR 5506 1,000 12.54 125 RECONSTRUCTION & DRIVERS FILLING OR GRADING TUNNELING BRIDGE OR CULVERT BUILDING QUARRYING STONE CR___ING TO BE SEPARATELY RATED ______NG OR GRADING TUNNELING BRIDGE OR CULVERT BUILDING QUARRYING STONE CRUSHING TO BE SEPARATELY RATED METAL CEILING OR WALL COVERING 5538 300 12.58 38 INSTALLATION & SHOP, DRIVERS CLEANER - DEBRIS REMOVAL 5610 1,120,000 7.45 83,440 TRUCKING: 7230 300 6.78 20 PARCEL OR PACKAGE DELIVERY - ALL EMPLOYEES & DRIVERS FREIGHT HANDLING NOC: STATE ACT ONLY 7360 32,000 11.02 3,526 DRIVERS, CHAUFFEURS AND THEIR HELPERS 7380 53,200 5.60 2,979 NOC-COMMERCIAL ALE OR BEER DEALER - WHOLESALE - & 7390 1,600 5.35 86 DRIVERS GARBAGE WORKS 7590 241,500 6.56 15,842 FLORIST-STORE-DRIVERS 8001 100 2.48 2 _____ CLOTHING, WEARING APPAREL OR DRY 8008 900 1.54 14 _____ RETAIL - ----------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 TENNESSEE - ------------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. STORE: HARDWARE 8010 600 2.73 16 STORE: RETAIL NOC 8017 117,500 2.23 3,958 STORE: GROCERY WHOLESALE 8018 76,000 5.29 4,020 STORE: MEAT, FISH OR POULTRY DEALER - 8021 136,200 8.39 11,427 WHOLESALE COLD STORAGE LOCKER - FROZEN FOODS 8031 17,200 6.84 1,176 STORE: SHOE WHOLESALE 8032 500 3.37 17 DEPARTMENT STORES--RETAIL 8039 160,100 1.84 2,946 FURNITURE STORES --WHOLESALE OR RETAIL - 8044 10,000 4.06 406 DRIVERS AUTOMOBILE ACCESSORY STORES - RETAIL - 8046 6,200 2.79 173 NOC - & DRIVERS BUILDING MATERIAL DEALER - NEW MATERIALS 8058 1,600 4.37 70 ONLY: STORE EMPLOYEES MACHINERY DEALER NOC - STORE OR YARD - 8107 1,000 4.91 49 & DRIVERS PLUMBERS' SUPPLIES DEALER & DRIVERS NPD 8111 1,500 4.07 61 CONTRACTOR'S PERMANENT YARD 8227 912,000 4.86 44,323 PLUMBER YARD - NEW MATERIALS ONLY: 8232 69,400 7.89 5,476 ALL OTHER EMPLOYEES & YARD, WAREHOUSE, DRIVERS RUBBER STOCK DEALER - USED - AND 8264 7,400 9.07 671 DRIVERS NPD STORAGE WAREHOUSE - COLD 8291 13,000 7.49 974 STORAGE WAREHOUSE NOC 8292 251,200 7.24 18,187 STORAGE WAREHOUSE - FURNITURE - & 8293 27,300 11.10 3,030 - ---------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 TENNESSEE - ------------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. DRIVERS AUTOMOBILE SERVICE OR REPAIR CENTER & 8380 91,400 4.49 4,104 DRIVERS FIELD BONDED WAREHOUSING - ALL EMPLOYEES 8710 600 2.77 17 & CLERICAL MARINE APPRAISER OR SURVEYOR 8720 900 2.11 19 ADDRESSING OR MAILING CO & CLERICAL 8800 10,100 3.19 322 AMUSEMENT PARK OR EXHIBITION 9016 4,500 4.21 189 OPERATION & DRIVERS CLUB - COUNTRY, GOLF, FISHING OR YACHT - 9060 6,651 3.45 229 & CLERICAL CLUB NOC & CLERICAL 9061 1,000 2.79 28 RESTAURANT: FAST FOODS 9083 339,345 3.75 12,725 RELIGIOUS ORGANIZATION: 9101 1,000 4.00 40 ALL OTHER EMPLOYEES LAWN MAINTENANCE - COMMERCIAL OR 9102 500 5.97 30 DOMESTIC & DRIVERS CODES 9102 AND 0042, LANDSCAPE GARDENING AND DRIVERS MAY BE ASSIGNED TO THE SAME RISK. THE PAYROLL OF AN INDIVIDUAL EMPLOYEE MAY BE DIVIDED AND ALLOCATED BE- TWEEN CODES 0042 AND 9102 PROVIDED THAT THE ENTRIES ON THE ORIGINAL RECORDS OF THE INSURED DISCLOSE AN ALLOCATION OF EACH INDIVIDUAL'S PAYROLL. AN ESTIMATE OR PERCENTAGE ALLOCATION OF PAYROLL IS NOT PERMITTED. THEATRE NOC: ALL OTHER EMPLOYEES 9154 23,600 3.09 729 CLUB - SHOOTING & DRIVERS 9180 150 6.27 9 ______, GARBAGE OR REFUSE COLLECTION & 9403 10,100 8.90 899 - ---------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 TENNESSEE - ------------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL RENUMERATION RENUMBERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. PAINTING: SHOP ONLY & DRIVERS NPD 9501 200 5.15 10 CARPET INSTALLATION 9521 700 6.16 43 AUTOMOBILE, BUS, TRUCK, OR TRAILER 9522 5,200 4.27 222 BODY MFG: UPHOLDSTERING UNMODIFIED PREMIUM 352,033 INCREASED LIMITS-EMPLOYER LIABILITY 3.3% 9812 11,617 TOTAL UNMODIFIED PREMIUM 363,650 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 (76,367) SCHEDULE MODIFICATION 25% 9887 (71,821) MODIFIED STANDARD PREMIUM 215,462 LOSS REIMBURSEMENT $250,000 9862 (119,626) UNDISCOUNTED PREMIUM 95,836 TOTAL ESTIMATED ANNUAL PREMIUM 95,836 TOTAL DUE 95,836 - ---------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-40 TEXAS - ------------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUMERATION REMUNERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. OUTSOURCE INTERNATIONAL, INC. NEED ADDRESS ENTIRE STATE, TX 99999 COTTON CLASSING CLASSERS CLERKS & 8810 18,136,647 0.49 88,870 MICRONAIRE OPERATORS COTTON CLASSING: 9015 530 7.00 37 SAMPLE HANDLERS, PORTERS & DRIVERS UNMODIFIED PREMIUM 88,907 INCREASED LIMITS-EMPLOYER LIABILITY 2% 9812 1,778 T0TAL UNMODIFIED PREMIUM 90,685 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 (19,044) MODIFIED STANDARD PREMIUM 71,641 LOSS REIMBURSEMENT $250,000 9962 (30,326) UNDISCOUNTED PREMIUM 41,315 PREMIUM DISCOUNT - STOCK 0063 (8,431) TOTAL ESTIMATED ANNUAL PREMIUM 32,884 ASSESSMENTS/TAXES .59% 0088 423 TOTAL DUE 33,307 - ---------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY LARGE RISK RATING PLAN ENDORSEMENT Endorsement forms a part of, and is effective from the inception of, Policy Number RMWC 217-79-40 Issued to: OUTSOURCE INTERNATIONAL, INC. by: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA THE "FINAL PREMIUM" for the policies listed herein will be determined according to this Rating Plan. PLEASE READ IT CAREFULLY PART I. GENERAL TERMS AND CONDITIONS ARTICLE 1. PREMIUM CALCULATION A. The "FINAL PREMIUM" for the policies described in Section I of the "SCHEDULE" of this endorsement and other policies as may be added by endorsement thereto (the "Policies") shall be the sum of the premiums as determined below under Section B and Section C of this Article. The "FINAL PREMIUM " may be limited by the operation of the provision below titled "Maximum Insurance Cost", if shown in the "SCHEDULE" as applicable to this Plan. B. The portion of the "FINAL PREMIUM" for the kinds of insurance on risks in the states described in Section 2. of the "SCHEDULE " of this endorsement shall be calculated solely according to the terms of the policies applicable thereto, without reference to this endorsement. C. The portion of the "FINAL PREMIUM" for all other risks covered by the policies to which this endorsement applies shall be the result of the following calculation, applied separately for each kind of insurance in each state: THE SUM OF THE AMOUNTS CALCULATED UNDER ITEMS 1, 2, 3, AND 4 BELOW, DIVIDED BY ITEM 5 (THE RESULT LIMITED TO NOT GREATER THAN THE MAXIMUM INSURANCE COST, IF APPLICABLE); PLUS ITEM 6. ITEM 1. The sum of all "INCURRED SUBJECT LOSSES". subject to the following: 1. REIMBURSABLE OR DEDUCTIBLE LOSSES EXCLUDED: This Item 1. will be reduced by the amount that you must reimburse us for under any Loss Reimbursement or Deductible terms that are a part of the policy or an endorsement attached to the policy. 2. EXCESS OF AGGREGATE STOP AMOUNT EXCLUDED: If an Aggregate Stop Amount is shown in the "SCHEDULE", we will not use more than such Aggregate Stop Amount less items i) and ii) below, as the Incurred Subject Losses in this Item 1 of this formula for all policies to which this Large Risk Rating Plan applies, subject to the Aggregate Stop Limit described in item 3 below. i) all Incurred Subject Losses that you have reimbursed us for under any Loss Reimbursement or Deductible terms that are a part of the policy or an endorsement attached to the policy, and ii) if so stated in the "SCHEDULE", such amounts as are described in the "SCHEDULE" that you have paid as self-insured losses, INDEX: If an Index Rate and an Index "BASIS" are shown in the "SCHEDULE", the Aggregate Stop Amount shown in the "SCHEDULE" is only an estimate. The Aggregate Stop Amount will be finally determined by multiplying the Index Rate by the final Index "BASIS " as determined by our audit of your books and records. 3. EXCESS OF AGGREGATE STOP LIMIT INCLUDED: If an Aggregate Stop Limit is shown in the "SCHEDULE", that Limit is the most Incurred Subject Losses that we will i) not require you to reimburse us for as reimbursable or deductible losses and ii) exclude from this Item 1 of the premium calculation formula for all policies to which this Large Risk Rating Plan applies because of the application of item 2 above. Neither the Aggregate Stop Amount nor the Aggregate Stop Limit will be reduced on account of the cancellation of any policy to which this Endorsement applies. Form No. 64478 (7/96) Copyright 1996 American International Group Inc. Page 1 of 11 LARGE RISK RATING PLAN ENDORSEMENT ITEM 2. PROVISIONS FOR SERVICE CHARGES AND EXPENSES. (except Taxes and Assessments based on the "FINAL PREMIUM"), and identified in Part II, Section 7., Part B. of this Endorsement. The entire amount of each such provision for all policies described in Section 1. of Part II. of this endorsement is shown as an amount or as a product of other values in the "SCHEDULE". Each such provision or the sum of any or all such provisions is subject to any Minimum amount shown as applicable to it in the "SCHEDULE". We will apportion the entire amount of each such provision to each kind of insurance and state under all policies described in Section 1. of Part II. of this endorsement in proportion to the respective "STANDARD PREMIUM" of each, except that: 1. Provision for claims services will be apportioned in proportion to respective Incurred Subject Losses, and 2. Provision for taxes and assessments on Losses or on "STANDARD PREMIUM" will be calculated individually for each type of insurance and state under all policies described in Section 1. of Part II. of this endorsement according to the factors and tax or assessment "BASES" shown in Section 9 of Part 11 of this endorsement. ITEM 3. WORKERS' COMPENSATION EXCESS PREMIUMS (EXCLUDING PREMIUM FOR INSURANCE IN EXCESS OF YOUR QUALIFIED SELF-INSURANCE): The amount of the Workers' Compensation Excess Premium is shown as an amount or as a product of other values in the "SCHEDULE". Such Premium is subject to any Minimum amount shown as applicable to it in the "SCHEDULE". The entire amount of the Workers' Compensation Excess Premium shall be apportioned to each covered state under all policies described in Section 1. of Part 11. of this endorsement in proportion to the respective Workers' Compensation "STANDARD PREMIUMS" of each. ITEM 4. INSURANCE CHARGE AND CONTINGENCY PREMIUM: The amount of the Insurance Charge and Contingency Premium for all the policies described in Section 1. of Part II. of this endorsement is shown as an amount or as a product of other values in the "SCHEDULE". The total Insurance Charge and Contingency Premium in the premium is subject to any Minimum amount shown in the "SCHEDULE". The Insurance Charge and Contingency Premium in the premium for the kinds of insurance in the states described in Section 2. of Part II. of this endorsement will be the amount remaining in such premium after deduction of the amounts of Items 1., 2., 3., 5., and 6. that we attribute thereto in accordance with this endorsement. The balance of the total Insurance Charge and Contingency Premium shall be apportioned to all other kinds of insurance and states in proportion to the respective "STANDARD PREMIUMS" of each. ITEM 5. TAX AND ASSESSMENTS DIVISOR: One (1.000) less the sum of the Tax and Assessment Factors shown in Part II, Section 9 as applicable to "FINAL PREMIUM" as the base of taxation or assessment. ITEM 6. NON-SUBJECT PREMIUMS: Premiums identified in Part 11, Section 7, Part C in the "SCHEDULE", after adjustment for increase or decrease in the rating "BASES" thereof from such "BASES" estimated at the inception of this policy. D. If a MAXIMUM SUBJECT INSURANCE COST is shown in the "SCHEDULE", that amount is the most you must pay us as the sum of all reimbursements of Reimbursable or Deductible losses and all premiums, EXCEPT premiums identified in Part II, Section 7, Part C in the "SCHEDULE", under the policies. "Premiums" do not include amounts identified in policies, endorsements or premium audit reports as "Taxes" or "Surcharges". If an Index Rate and an Index "BASIS" for the Maximum Subject Insurance Cost is shown in the "SCHEDULE", the Maximum Subject Insurance Cost shown in the "SCHEDULE" is only an estimate. The Maximum Subject Insurance Cost will be finally determined by multiplying the Index Rate by the final Index "BASIS" as determined by our audit of your books and records. ARTICLE 2. SCHEDULE OF ADJUSTMENTS We have shown the estimated "FINAL PREMIUM" in Part II., Section 7. We will recalculate the estimated "FINAL PREMIUM" as soon as practicable after the First Valuation Date shown in the "SCHEDULE". We will thereafter recalculate the estimated "FINAL PREMIUM" annually until you and we agree in writing that no more recalculations will be done. Additional premium due us, or return premium due you, resulting from the calculation or recalculation of the estimated "FINAL PREMIUM" final "FINAL PREMIUM", will be payable according to a written Payment Agreement between you and us. Form No. 64478 (7/96) Copyright 1996 American International Group Inc. Page 2 of 11 LARGE RISK RATING PLAN ENDORSEMENT ARTICLE 3. DEFINITIONS A. "STANDARD PREMIUM" means the premium as calculated according to the terms of each applicable policy, without application of this Endorsement, subject to the following: 1. FOR WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE, "STANDARD PREMIUM" means the premium determined on the basis of our rates as approved by regulatory authority, the remuneration of your employees in the coverage period, your Experience Modifications and Schedule Modifications, Loss Constant, and Minimum Premiums. Determination of "STANDARD PREMIUM" will exclude: a) any discount that recognizes any reduction in our expense ratio based on premium size or other factors; or b) any discount for a Loss Reimbursement or Deductible Plan. c) Expense Constant. 2. FOR ALL OTHER INSURANCE, "STANDARD PREMIUM" is the premium as calculated according to the terms of each applicable policy for insurance within the "Subject Limits", without the application of this Endorsement and without reduction for: a) any discount that recognizes any reduction in our expense ratio based on premium size or other factors; or b) any discount for a Loss Reimbursement or Deductible Plan. B. "INCURRED LOSS" means the total amount we have paid and have reserved for payment under the terms of a policy described in Part II, Section I of the "SCHEDULE" as damages, benefits or indemnity because of an occurrence, accident, claim or suit, and all the "ALLOCATED LOSS ADJUSTMENT EXPENSES" ("ALAE") we incur in connection therewith, including 1. payments that you must reimburse us for under deductible or reimbursable policy terms, and 2. payments that you are NOT obligated to reimburse us for under deductible or reimbursable policy terms, and 3. reserves for the unpaid portion of such a loss, and 4. reserves for occurrences, accidents, claims or suits that have happened but have not been not reported to us, and for statistically expected loss development on claims that have been reported to us. C. "RETAINED AMOUNT" MEANS: 1. the amount that is specified as your Self-Insured Retention or as the Reimbursable or Deductible amount in the policy applicable to an "INCURRED LOSS"; or 2. if the foregoing does not apply, your "RETAINED AMOUNT" is the largest portion of the total damages, benefits or indemnity that we must pay because of an occurrence, accident, claim or suit that we will include in the computation of the "FINAL PREMIUM". Such amount is shown in Section 5 of the "SCHEDULE" for each type of insurance afforded under the Policies. D. A "INCURRED SUBJECT LOSS" means the entire "INCURRED LOSS" up to the sum of: 1. the damages, benefits or indemnity we must pay or have paid, up to the "RETAINED AMOUNT" shown in Section 5 of the "SCHEDULE" for the kind of insurance applicable to such damages, benefits or indemnity, and 2. "ALLOCATED LOSS ADJUSTMENT EXPENSES","ALAE") we incur in the amount calculated according to the "ALAE" Option shown in the "SCHEDULE" and described below. "ALLOCATED LOSS ADJUSTMENT EXPENSES" OPTIONS OPTION A: "Incurred Subject Loss" includes all or a part of all "ALAE" such that the "INCURRED SUBJECT LOSS" will not exceed the applicable "RETAINED AMOUNT". OPTION B: "Incurred Subject Loss" includes 100% of all "ALAE" OPTION C: "Incurred Subject Loss" includes all or a part of "ALAE" calculated according to the following formula: a) If we have NO obligation under the Policies to pay damages, benefits or indemnity, all "ALAE" up to the applicable "RETAINED AMOUNT" AND 50% of all ALAE in excess thereof; or b) If our obligation to pay damages, benefits or indemnity under the Policies exceeds zero ($0), all "ALAE" TIMES the amount of our obligation to pay damages, benefits or indemnity up to the applicable "RETAINED AMOUNT", DIVIDED BY the total amount of our obligation to pay damages, benefits or indemnity. OPTION D: "Incurred Subject Loss" includes NONE of the "ALAE". E. "ALLOCATED LOSS ADJUSTMENT EXPENSES" OR "ALAE" means all court costs and court expenses; pre- and post-judgment interest; fee for service of process; attorneys' fees; cost of undercover operative and detective services, costs of employing experts; costs for legal transcripts; costs for copies of any public records; costs of depositions and court-reported or recorded statements; costs and expense of subrogation; and any similar fee, cost or expense reasonably chargeable to the investigation, negotiation, settlement or defense of loss or a claim or suit against you, or to the protection and perfection of your or our subrogation rights. Form No. 64478 (7/96) Copyright 1996 American International Group Inc. Page 3 of 11 LARGE RISK RATING PLAN ENDORSEMENT "ALAE" shall not include loss adjustment expenses explicitly included in Item 2 of the premium calculation formula or otherwise explicitly included in the Rating Values shown in the "SCHEDULE"; nor the salary, employee benefits, or overhead of any of our employees, nor the fees of any attorney who is our employee or under our permanent retainer. F. "SCHEDULE" means "Part II. Schedule of Policies and Rating Values" herein. G. "BASIS" OR "BASES", (such as Payroll or Sales or Units or other variables) when used as the "BASIS" for determining the "FINAL PREMIUM" or a part thereof, shall have the meaning(s) defined in Section 10. of the "SCHEDULE" of this endorsement. H. "FINAL PREMIUM" means the premium for the insurance afforded under the policies described in Section 1. of the "SCHEDULE" of this endorsement and others as may be added by endorsement thereto, upon its final recalculation according to the terms of the policies and this endorsement. Prior to such final recalculation, the premium for such insurance is only the estimated premium. ARTICLE 4. EXCEPTIONS All exceptions, if any, to the provisions of Part I., Article 1, Article 2, or Article 3, or to Part II., are set forth in Section 11. of Part II. or in an addendum hereto. Form No. 64478 (7/96) Copyright 1996 American International Group Inc. Page 4 of 11 LARGE RISK RATING PLAN ENDORSEMENT PART II. SCHEDULE OF POLICIES AND RATING VALUES SECTION 1. THIS ENDORSEMENT APPLIES TO THE POLICIES DESCRIBED BELOW: a. Workers' Compensation and Employer's Liability Insurance Policies: RMWC 217-79-40 RMWC 217-79-45 RMWC 217-79-43 RMWC 217-79-46 RMWC 217-79-44 RMWC 217-49-48 b. Commercial General Liability Insurance Policies: c. Automobile Liability Insurance Policies: d. Other Insurance Policies (described): SECTION 2. PREMIUMS FOR INSURANCE ON RISKS IN STATES DESCRIBED BELOW WILL NOT BE ADJUSTED ACCORDING TO THIS ENDORSEMENT: KINDS OF INSURANCE STATES Workers Compensation Arizona, Massachusetts, Missouri, New Jersey, New York, Wisconsin SECTION 3. "ALLOCATED LOSS ADJUSTMENT EXPENSES" OPTIONS: (Refer to Article 3., "Definitions", Paragraph D.) Option A applies to WORKER'S COMPENSATION Option _ applies to _____________________ Option _ applies to _____________________ Option _ applies to _____________________ SECTION 4. FIRST VALUATION DATE: JULY, 1998 Form No. 64478 (7/96) Copyright 1996 American International Group Inc. Page 5 of 11 LARGE RISK RATING PLAN ENDORSEMENT SECTION 5. "RETAINED AMOUNTS": (Refer to Definitions) KIND OF INSURANCE "RETAINED AMOUNTS" BASIS OF RETENTION DESCRIPTION Workers' Compensation & $250,000 each Accident or each States' Acts Employer's Liability Person for Disease Coverages Workers' Compensation & $500,000 each Accident or each Federal Acts Employer's Liability Person for Disease Coverages Commercial General $ each Occurence Liability Product or Completed $ each Occurence Operations Liability Workers' Compensation & $ each Occurence Employer's Liability and General/Products Liability Combined Automobile Liability $ each accident Workers' Compensation, $ each Accident Employer's Liability, and Automobile Liability Combined All Kinds of Insurance $ each Occurence Combined SECTION 6. MAXIMUM SUBJECT INSURANCE COST OR AGGREGATE STOP AMOUNT AND LIMIT: a. Maximum Subject Insurance Cost: /bullet/ Aggregate Cap Purchased 6/11/97, adjustable according to item c. below; OR Aggregate Stop Amount: /bullet/ See Attached Quotation Sheet & Invoice - Page 6A & 6B, subject to item b. and adjustable according to item c. below. b. Aggregate Stop /bullet/ Financial Agreements are Being Revised c. Index Rate: ____________ per ___________ of _____________, the Index "BASIS". The Estimated Index "BASIS" is NA. Losses you incur to which no insurance under the policies listed in Section 1. of this Part II. "SCHEDULE" applies shall NOT be whether or when the Maximum Subject Insurance Cost or the Aggregate Stop Amount or the Aggregate Stop Limit have been reached, except as described herein: Exceptions: None Form No. 64478 (7/96) Copyright 1996 American International Group Inc. Page 6 of 11 AMERICAN INTERNATIONAL GROUP COMMERCIAL RISK DIVISION MEMORANDUM DIRECT DIAL: (770) 671-2251 FAX: (770) 399-4140 DATE: 6/11/97 TO: STEVE BECKER SEDGWICK - FAX NO. 954-761-2608 FROM: CARLA HORNIBROOK SENIOR UNDERWRITER SUBJECT: AGGREGATE QUOTE - OUTSOURCE Dear Steve: As per the client's instructions we are binding the 1997 aggregate quote as follows: Policy Term/Line - Workers Compensation - 1/1/1997 to 1/l/98 Aggregate Value - $6,000,000 Aggregate Value Adjustment - The $6,000,000 figure is a minimum of $6,000,000 or ($6,000,000 plus $2,182 per $100 of (Total Audited WC Payroll less 302,500,000)) whichever is greater. Aggregate Premium - $284,792 Minimum and Deposit. Full payment to be due upon receipt of bill. Premium Adjustment - The $284,792 premium figure is a minimum of $284,792 or ($284,792 plus $.104 per $100 of (Total Audited WC Payroll less 302,500,000)) whichever is greater. Offering is subject to execution and return of signed legal documents. The legals will be amended to include the aggregate. Upon presentation of revised documents, the Insured is to complete and return within 10 working days. Bound 6/11/97 Effective 1/1/97-98 Page 6A INVOICE NO. --------------------------------------- PAGE INVOICE DATE --------------------------------------- 1 OF 1 6/26/97 151108 Sedgwick of FL, Inc. --------------------------------------- 1555 Palm Bch Lakes Blvd #800 CUSTOMER NO. ACCOUNT EXECUTIVE West Palm Beach, FL 33402 --------------------------------------- OU021050 JJS SIMONE ---------------------------------------- PRODUCER ------------------- JJS SIMIONE REMIT TO: OutSource International Sedgwick of FL, Inc. 1144 East Newport Center Drive *** West Palm Beach *** Deerfield Beach,FL 33442 P.O. Box 92126 Chicago, IL 60675-2126 561-689-6190 [ILLEGIBLE INVOICE COPY BELOW] Page 6B LARGE RISK RATING PLAN ENDORSEMENT SECTION 7. THE RATING VALUES AND AMOUNTS shown below apply as estimated average or combined values or amounts TO all Policies described in Section I of this Part 11 above. We will calculate the final values by line and state according to this rating plan. PART A. ESTIMATED TOTAL "FINAL PREMIUM": - ---------------------------------------------------------------------------------------------- 1. Estimated Other Premiums from Part C below $0 2. Estimated Remainder of "FINAL PREMIUM" $1,513,225 a. Estimated "RETAINED AMOUNTS" & "ALIE" IN "FINAL PREMIUM" $127,043 b. Est. Expense Provision & WC Excess Premium from Part B $1,386,182 3. ESTIMATED "FINAL PREMIUM" $1,513,225 - ---------------------------------------------------------------------------------------------- - ---------------------------------------------------------------------------------------------- PART B. EXPENSES PROVISION AND WORKERS' COMPENSATION EXCESS PREMIUM - ---------------------------------------------------------------------------------------------- EXPENSE ITEMS RATES ADJUSTMENT MINIMUM ESTIMATED AMOUNT "BASES"/PER Y/N Administration Expense See Section 11 $ 100 Payroll Y-90% $465,142 Claims Administration Fee $571,040 $ $ $ $ $ $ $ $ Taxes & Assessments on "INCURRED Refer to Table of Taxes & Assessments $ Included LOSSES" or "STANDARD PREMIUM" Insurance Charge & Contingency $ Premium - --------------------------------------------------------------------------------------------- SUBTOTAL A - --------------------------------------------------------------------------------------------- Workers Compensation Excess See Section 11 $100 Payroll Y-100% $350,000 Premium - --------------------------------------------------------------------------------------------- SUBTOTAL B - --------------------------------------------------------------------------------------------- Taxes on "FINAL PREMIUM" Refer To Table Of Taxes & Assessments $ ESTIMATED EXPENSE PROVISION AND WORKERS' COMPENSATION EXCESS PREMIUM $ 1,386,182 - --------------------------------------------------------------------------------------------- PART C. OTHER PREMIUMS - ------------------------------------------------------------------------------------------------------- COVERAGE DESCRIPTION RATES PER "BASIS" TYPES ESTIMATED "BASIS" ESTIMATED PREMIUM (e.g. Payroll, Sales) AMOUNTS $ $ $ $ $ $ ESTIMATED TOTAL OTHER PREMIUMS $ - ------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------- PART D. SUMMARY OF EXPECTED FINAL COST - ------------------------------------------------------------------------------- ESTIMATED "FINAL PREMIUM" $1,513,225 EXPECTED REIMBURSABLE OR DEDUCTIBLE LOSSES AND "ALAE" $3,672,957 SPECIAL TAXES AND SURCHARGES NOT INCLUDED ABOVE $ 26,281 $ $ EXPECTED TOTAL FINAL COST $5,212,463 - ------------------------------------------------------------------------------- Form No. 64478 (7/96) Copyright 1996 American International Group Inc. Page 7 of 11 LARGE RISK RATING PLAN ENDORSEMENT SECTION 8. CLAIMS SERVICE CHARGES (_____) If checked here, refer to separate Fee Schedules attached and made a part of this Endorsement. THE CLAIMS SERVICE PROVIDER IS GALLAGHER BASSETT SERVICES, INC. CLAIMS SERVICES FEE SCHEDULE PART 1 - RATES PER CLAIMANT TYPE OF CLAIM RATE PER CLAIMANT ESTIMATED NO. OF CLAIMANTS ESTIMATED FEE WC Medical Only $90 2,456 $221,040 WC Other than Medical Only $700 500 $350,000 General Liability, Not Products Products Liability Incident Reports Auto Liability Private Passenger Commercial Types Auto Medical Payments Auto Physical Damage Occupational Disease ESTIMATED TOTAL RATE-PER-CLAIMANT FEE $571,040 FEE SCHEDULE PART 2., TIME AND EXPENSES TYPE OF CHARGE RATE PER ESTIMATED AMOUNT Opening File Charge Statistical File Charge Investigating Service by Employed Staff Adjuster General Adjuster Executive General Adjuster Heavy Equipment Appraiser Auto Damage Appraiser Property Damage Appraiser Supervisor Examiner Account Manager Subcontracted investigations and appraisals: Clerical & Statistical Processing: Other Expenses, including Telephone Postage Mileage, Tolls, Parking Photocopy Photography Transportation Overhead All Services outside of the continental USA ESTIMATED TOTAL TIME AND EXPENSE $ ESTIMATED TOTAL CLAIMS SERVICE EXPENSES $571,040 Form No. 64478 (7/96) Copyright 1996 American International Group Inc. Page 8 of 11 LARGE RISK RATING PLAN ENDORSEMENT SECTION 9. Taxes & Assessments ("Taxes"): INCLUDED IN ADMINISTRATION EXPENSE GENERAL AUTO WORKERS COMPENSATION LIABILITY LIABILITY - ----------------------------------------------------------------------------------------------------- BASE NOT REDUCED FOR DEDUCTIBLE BASE REDUCED FOR DEDUCTIBLE BASE BASE DISCOUNTS OR LOSS REIMBURSEMENTS DISCOUNTS AND LOSS REIMBURSEMENTS REDUCED REDUCED "BASES" TAX* ON TAX* ON RML* ON TAX* ON TAX* ON RML* ON TAX* ON TAX* ON PREMIUM LOSSES PREMIUM PREMIUM LOSSES PREMIUM PREMIUM PREMIUM ALL STATES - ------------------------------------------------------------------------------------------------------ ALL STATES EXCEPT WHERE SPECIFIC RATES ARE SHOWN BELOW - ------------------------------------------------------------------------------------------------------ RATES BY LINE AND STATE AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH Form No. 64478 (7/96) Copyright 1996 American International Group Inc. Page 9 of 11 LARGE RISK RATING PLAN ENDORSEMENT SECTION 9. Taxes & Assessments ("Taxes")(Continued) LINE OF GENERAL AUTO INSURANCE WORKERS COMPENSATION LIABILITY LIABILITY - ----------------------------------------------------------------------------------------------------- BASE NOT REDUCED FOR DEDUCTIBLE BASE REDUCED FOR DEDUCTIBLE BASE BASE DISCOUNTS OR LOSS REIMBURSEMENTS DISCOUNTS AND LOSS REIMBURSEMENTS REDUCED REDUCED "BASES" TAX* ON TAX* ON RML* ON TAX* ON TAX* ON RML* ON TAX* ON TAX* ON PREMIUM LOSSES PREMIUM PREMIUM LOSSES PREMIUM PREMIUM PREMIUM ALL STATES - ------------------------------------------------------------------------------------------------------ RATES BY LINE AND STATE OK OR PA RI SC SD TN TX USLH* UT VT VA WA WV WI WY NOTE: "Tax on Premium" includes Premium and Franchise Taxes and Assessments (including states' Workers' Compensation Boards and Rating Bureaus) levied on the "BASIS" of Premium as defined by them. However, special taxes and surcharges shown as such in the Policies are NOT included therein and are payable in addition to Premium Taxes and Assessments calculated according to this Endorsement. For General and Auto Liability (but not for Worker's Compensation), the Tax rates also include Residual Market Assessments, if any. "Tax on Losses" includes principally "Second Injury Funds" assessments and certain other assessments by a variety of states' funds. "RML's" are Residual Market Assessments for Workers Compensation, payable in addition to all other taxes and assessments, to fund deficits (if any) in the operating results of states' assigned risk pools. "USL's means "US Longshore and Harbor Workers' Compensation Act -- Special Fund", a fund which pays for compensation is certain cases in which the employee suffers a second injury. SECTION 10. ADDITIONAL DEFINITIONS: PAYROLL: SALES: UNITS: OTHER: Form No. 64478 (7/96) Copyright 1996 American International Group Inc. Page 10 of 11 LARGE RISK RATING PLAN ENDORSEMENT - -------------------------------------------------------------------------------- SECTION 11. EXCEPTIONS: THE ADMINISTRATION EXPENSE WILL BE ADJUSTABLE @.16914 PER $100 OF TOTAL WORKER'S COMPENSATION PAYROLL FOR THE FIRST $275,000,000 OF PAYROLL AND ADJUSTABLE @.050742 FOR ANY PAYROLL WHICH EXCEEDS $275,000,000. THE EXCESS WORKER'S COMPENSATION CHARGE WILL BE ADJUSTABLE @.1272727 PER $100 OF TOTAL WORKER'S COMPENSATION PAYROLL FOR THE FIRST $275,000,000 OF PAYROLL AND ADJUSTABLE @.0381818 FOR ANY PAYROLL WHICH EXCEEDS $275,000,000. BY THE SIGNATURE OF YOUR AUTHORIZED REPRESENTATIVE BELOW, YOU SIGNIFY THAT THIS RATING PLAN HAS BEEN EXPLAINED TO YOU AND YOU AGREE TO ITS TERMS. THIS ENDORSEMENT IS INVALID UNLESS SIGNED BY OUR AUTHORIZED REPRESENTATIVE. OUTSOURCE INTERNATIONAL, INC. ------------------------------ ------ ----------------------------- ------ Your Authorized Representative Date Our Authorized Representative Date Type Names: --------------------------- ------------------------------------ - -------------------------------------------------------------------------------- Form No. 64478(7/96) Copyright 1996 PAGE 11 of 11 American International Group, Inc. DEFENSE BASE ACT COVERAGE ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. BY THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the work described in the Schedule or described on the Information Page as subject to the Defense Base Act. The policy applies to that work as though the location included in the description of the work were a state named in Item 3.A. of the Information Page. General Section C. WORKERS' COMPENSATION LAW is replaced by the following: C. WORKERS' COMPENSATION LAW Workers' Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page and the Defense Base Act (42 USC Sections 1651-1654). It includes any amendments to those laws that are in effect during the policy period. It does not include any other federal workers or workmen's compensation law, other federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. Part Two (Employers Liability Insurance), C. Exclusions., exclusion 8, does not apply to work subject to the Defense Base t. Schedule DESCRIPTION OF WORK NO WORK AT THIS TIME. IT IS AGREED THAT IF ANY WORK IS SUBJECT TO THE DEFENSE BASE ACT, THE INSURER WILL ENDORSE THE POLICY WITHIN SIXTY (60) DAYS OF NOTIFICATION. WC 00 01 01 A COUNTERSIGNED BY ___________________________ (ED. 4-92) AUTHORIZED REPRESENTATIVE LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT COVERAGE ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to work subject to the Longshore and Harbor Workers' Compensation Act in a state shown in the Schedule. The policy applies to that work as though that state were listed in Item 3.A. of the Information Page. General Section C. WORKERS' COMPENSATION LAW is replaced by the following: C. WORKERS' COMPENSATION LAW Workers' Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page and the Longshore and Harbor Workers' Compensation Act (33 USC Sections 901-950). It includes any amendments to those laws that are in effect during the policy period. It does not include any other federal workers or workmen's compensation law, other federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. Part Two (Employers Liability Insurance), C. Exclusions., exclusion 8, does not apply to work subject to the Longshore and Harbor Workers' Compensation Act. This endorsement does not apply to work subject to the Defense Base Act, the Outer Continental Shelf Lands Act, or the Nonappropriated Fund Instrumentalities Act. Schedule STATE LONGSHORE AND HARBOR WORKERS' - ----- COMPENSATION ACT COVERAGE PERCENTAGE ------------------------------------ ALASKA 25.00 ALABAMA 122.00 ARKANSAS 110.00 CONNECTICUT 2.00 DISTRICT OF COLUMBIA 28.00 FLORIDA 223.00 GEORGIA 113.00 IOWA 39.00 ILLINOIS 28.00 INDIANA 90.00 KENTUCKY 89.00 LOUISIANA 126.00 MASSACHUSETTS 38.40 MICHIGAN 62.00 MINNESOTA 58.00 MISSOURI 29.00 MISSISSIPPI 157.00 NORTH CAROLINA 68.00 NEBRASKA 76.00 The rates for classifications with code numbers not followed by the letter "F" are rates for work not ordinarily subject to the Longshore and Harbor Workers' Compensation Act. If this policy covers work under such classifications, and if the work is subject to the Longshore and Harbor Workers' Compensation Act, those non-F classification rates will be increased by the Longshore and Harbor Workers' Compensation Act Coverage Percentage shown in the Schedule. WC 00 01 01 A COUNTERSIGNED BY ___________________________ (ED. 4-92) AUTHORIZED REPRESENTATIVE ENDORSEMENT This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-40 Issued to: OUTSOURCE INTERNATIONAL, INC. By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA Schedule - (continued) Longshoremen's and Harbor Workers' State Compensation Act Coverage Percentage NEW HAMPSHIRE 99.00 NEW JERSEY 50.00 NEW MEXICO 97.00 NEW YORK 83.60 PENNSYLVANIA 83.60 SOUTH CAROLINA 111.00 SOUTH DAKOTA 54.00 TENNESSEE 90.00 TEXAS 61.00 ___________________________ AUTHORIZED REPRESENTATIVE Issue Date: 04/10/97 lwOl74 ALTERNATE EMPLOYER ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only with respect to bodily injury to your employees while in the course of special or temporary employment by the alternate employer in the state named in Item 2 of the Schedule. Part One (Workers Compensation Insurance) and Part Two (Employers Liability Insurance) will apply as though the alternate employer is insured. If an entry is shown in Item 3 of the Schedule the insurance afforded by this endorsement applies only to work you perform under the contract or at the project named in the Schedule. Under Part One (Workers Compensation Insurance) we will reimburse the alternate employer for the benefits required by the workers compensation law if we are not permitted to pay the benefits directly to the persons entitled to them. The insurance afforded by this endorsement is not intended to satisfy the alternate employer's duty to secure its obligations under the workers compensation law. We will not file evidence of this insurance on behalf of the alternate employer with any government agency. We will not ask any other insurer of the alternate employer to share with us a loss covered by this endorsement. Premium will be charged for your employees while in the course of special or temporary employment by the alternate employer. The policy may be cancelled according to its terms without sending notice to the alternate employer. Part Four (Your Duties If Injury Occurs) applies to you and the alternate employer. The alternate employer will recognize our right to defend under Parts One and Two and our right to inspect under Part Six. SCHEDULE 1. ALTERNATE EMPLOYER ADDRESS 2. STATE OF SPECIAL OR TEMPORARY EMPLOYMENT 3. CONTRACT OR PROJECT "ANY CLIENT IS INCLUDED AS AN ALTERNATE EMPLOYER AS RESPECTS THE USE OF TEMPORARY OR LEASED EMPLOYEES OF OUTSOURCE INTERNATIONAL AND AFFILIATED RELATED COMPANIES PER WRITTEN AGREEMENT BETWEEN THE PARTIES PRIOR TO LOSS" WC 00 03 01 A COUNTERSIGNED BY ___________________________ (ED. 02-89) AUTHORIZED REPRESENTATIVE VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement adds Voluntary Compensation Insurance to the policy. A. HOW THIS INSURANCE APPLIES This insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must be sustained by an employee included in the group of employees described in the Schedule. 2. The bodily injury must arise out of and in the course of employment necessary or incidental to work in a state listed in the Schedule. 3. The bodily injury must occur in the United States of America, its territories or possessions, or Canada, and may occur elsewhere if the employee is a United States or Canadian citizen temporarily away from those places. 4. Bodily injury by accident must occur during the policy period. 5. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. B. WE WILL PAY We will pay an amount equal to the benefits that would be required of you if you and your employees described in the Schedule were subject to the workers compensation law shown in the Schedule. We will pay those amounts to the persons who would be entitled to them under the law. C. EXCLUSIONS This insurance does not cover: 1. any obligation imposed by a workers compensation or occupational disease law, or any similar law. 2. bodily injury intentionally caused or aggravated by you. D. BEFORE WE PAY Before we pay benefits to the persons entitled to them, they must: 1. Release you and us, in writing, of all responsibility for the injury or death. 2. Transfer to us their right to recover from others who may be responsible for the injury or death. 3. Cooperate with us and do everything necessary to enable us to enforce the right to recover from others. If the persons entitled to the benefits of this insurance fail to do those things, our duty to pay ends at once. If they claim damages from you or from us for the injury or death, our duty to pay ends at once. WC 00 03 101 A COUNTERSIGNED BY ___________________________ (ED. 8-91) AUTHORIZED REPRESENTATIVE Page 1 of 2 E. RECOVERY FROM OTHERS If we make a recovery from others, we will keep an amount equal to our expenses of recovery and the benefits we paid. We will pay the balance to the persons entitled to it. If the persons entitled to the benefits of this insurance make a recovery from others, they must reimburse us for the benefits we paid them. F. EMPLOYERS LIABILITY INSURANCE Part Two (Employers Liability Insurance) applies to bodily injury covered by this endorsement as though the State of employment shown in the Schedule were shown in Item 3.A of the Information Page. Schedule DESIGNATED WORKERS EMPLOYEES STATE OF EMPLOYMENT COMPENSATION LAW - --------- ------------------- ---------------- All officers and ALL STATES EXCEPT State of Hire employees not subject UT,WI,AZ,MD,VA,CA to the Workers Compensation ID,OR Law except Masters or Members of the crew of any vessel. This endorsement does not apply in New Jersey, Nevada, North Dakota, Ohio, Washington, Wisconsin, West Virginia, Wyoming, and Maine. WC 00 03 11 A COUNTERSIGNED BY ___________________________ (ED. 8-91) AUTHORIZED REPRESENTATIVE Page 2 of 2 EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA The premium for the policy will be adjusted by an experience rating modification factor. The factor was not available when the policy was issued. The factor, if any, shown on the Information Page is an estimate. We will issue an endorsement to show the proper factor, if different from the factor shown, when it is calculated. WC 00 04 03 COUNTERSIGNED BY ___________________________ (ED. 4-84) AUTHORIZED REPRESENTATIVE NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA Experience rating is mandatory for all eligible insureds. The experience rating modification factor, if any, applicable to this policy, may change if there is a change in your ownership or in that of one or more of the entities eligible to be combined with you for experience rating purposes. Change in ownership includes sales, purchases, other transfers, mergers, consolidations, dissolutions, formations of a new entity and other changes provided for in the applicable experience rating plan manual. You must report any change in ownership to us in writing within 90 days of such change. Failure to report such changes within this period may result in revision of the experience rating modification factor used to determine your premium. THIS ENDORSEMENT IS NOT APPLICABLE IN NEW JERSEY, PENNSYLVANIA, MICHIGAN, ALASKA, CALIFORNIA, DELAWARE, MAINE OR TEXAS. WC 00 04 14 COUNTERSIGNED BY ___________________________ (ED. 7-90) AUTHORIZED REPRESENTATIVE LOSS REIMBURSEMENT ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA PLEASE READ IT CAREFULLY. This Endorsement applies solely between you and us. It does not affect the rights of others under this policy. I. Payment and Reimbursement Conditions a. We will pay the sum of: 1. all benefits payable under PART ONE - WORKERS COMPENSATION INSURANCE; and 2. up to our limit of liability, all sums you legally must pay as damages to which PART TWO - EMPLOYERS LIABILITY applies; and 3. all benefits payable under PART THREE - OTHER STATES INSURANCE; and 4. all benefits or damages payable under any endorsements attached to the policy. b. You will reimburse us promptly up to the reimbursement limit(s) shown in the Schedule for any amounts we have so paid. You agree further to reimburse us for any "allocated loss adjusting expense" we pay according to the election indicated by an "X" below. If we make no payment, you must reimburse us for all "allocated loss adjusting expense". If no election is indicated, election C applies. Your obligation to reimburse us for "allocated loss adjusting expense" applies separately to "each accident" or, for bodily injury by disease, to "each claim". [X] A. All allocated loss adjusting expenses up to the amount by which the applicable "Each Accident" or "Each Claim" reimbursement limit exceeds the amount you must reimburse us for payments we make under Section I.A. above. B. All allocated loss adjusting expenses. C. A part of all allocated loss adjusting expenses in the proportion that the sum you must reimburse us for payments we make under I.A. above bears to all sums payable by us thereunder. c. If a Limit is shown in the Schedule as "Aggregate", that Limit is the most you must reimburse us for all benefits and all damages (but not "allocated loss adjustment expense") that we pay under this policy. The "aggregate" will not be reduced if this policy is issued for a term of less than one year, or if the policy or this endorsement is canceled before the end of the policy period. If no "Aggregate" Limit is shown in the Schedule, no aggregate limit applies to your reimbursement obligation. No limit on the Company's liability under the policy or any endorsement is increased or reinstated by this endorsement or by any reimbursement to us under the terms of this endorsement. WC53138 (ED. 2-92) 1 of 3 II. General Conditions A. Duties a. The first Named Insured shown in the Information Page agrees and is authorized to reimburse us for any reimbursable amounts we pay on behalf of any Insureds. b. each Named Insured is jointly and severally liable for all reimbursable amounts under this policy. c. All other terms of the policy, including those which apply to (1) our right and duty to defend any claim, proceeding or suit against you, and (2) your duties if injury or disease occurs, apply without change on account of this endorsement. B. Cancellation of This Endorsement You must reimburse us for any amounts that we pay within the Reimbursement Limits, and for your share of the "Allocated Loss Adjustment Expense", within 15 days of your receipt of an invoice from us. You must deliver to us such instruments of financial security, or amendments thereto, as we may require, within 15 days of our demand therefor. If you fail to do either, we may cancel this endorsement by mailing or delivering written notice to you not less than 10 days prior to the effective date of such cancellation stating the day and hour the cancellation is to take effect. Proof of the mailing of such notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. If we cancel this endorsement, you must pay us within 15 days of our invoice an additional premium that we will specify, calculated according to our rates and rules as filed and approved by regulatory agencies having jurisdiction. C. Recovery From Others We have your rights and the rights of persons entitled to the benefits of this insurance to recover all payments, including those within your reimbursement limit, from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. If we recover any payment we made under this policy from anyone liable for the injury, the amount we recover will first be applied to any payments we made in excess of the reimbursement limit or in excess of the "aggregate", and to our expenses in obtaining the recovery. The remainder of the recovery, if any, will be applied to reduce the amount that is reimbursable by you. D. Premium A discount in the premium for this policy is shown in the Schedule(s), calculated in accordance with our rating plan as filed and approved by regulatory agencies having jurisdiction. In the event that after the effective date of this policy additional or increased taxes or assessments are imposed upon us, not included in the calculation of the estimated annual premium hereof, we will recalculate the premium to include such additional costs and will reduce the discount accordingly. You will pay us any additional premium thus calculated promptly upon notice. III. Definitions 1. "Allocated loss adjustment expense" means claim adjustment expense allocated by us directly to particular claims. Such expenses shall include, but not be limited to, attorneys' fees for claims in suit, court costs, and other specific items of expense such as fees for medical examinations, expert testimony, laboratory, x-ray and autopsy services, stenographic services, witnesses and summonses, and copies of documents. WC53138 (ED. 2-92) 2 of 3 2. "Claim" means each demand you receive for: a. benefits required of you by the Workers' Compensation law, including a filing by your employee or by others legally entitled to do so on his or her behalf for such benefits with an agency authorized by law, and suit or other proceedings brought by your employee for such benefits or damages; or b. damages covered by this policy. SCHEDULE COVERAGE REIMBURSEMENT LIMITS Bodily Injury by Accident $250,000 Each Accident Bodily Injury by Disease $250,000 Each Claim All Covered Bodily Injury NOT APPLICABLE Aggregate STATES ALABAMA TEXAS ALASKA ARKANSAS CONNECTICUT DISTRICT OF COLUMBIA FLORIDA GEORGIA ILLINOIS INDIANA IOWA KENTUCKY LOUISIANA MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI NEBRASKA NEW HAMPSHIRE NEW MEXICO NEW YORK NORTH CAROLINA PENNSYLVANIA SOUTH CAROLINA SOUTH DAKOTA TENNESSEE C53138 COUNTERSIGNED BY ___________________________ (ED. 2-92) AUTHORIZED REPRESENTATIVE 3 of 3 ALASKA SURCHARGE This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA Companies writing property and casualty insurance business in Alaska are required to participate in the Alaska Insurance Guarantee Association. If a company becomes insolvent the Alaska Insurance Guarantee Association settles unpaid claims and assesses each insurance company for its fair share. Alaska law requires all companies to surcharge policies to recover these assessments. Your policy has been surcharged to the amount stated below. SURCHARGE AMOUNT: $0 SURCHARGE PERCENT: .0000 WC 54 00 02 COUNTERSIGNED BY ___________________________ (ED. 1-90) AUTHORIZED REPRESENTATIVE ALASKA LIMIT OF LIABILITY ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by Part Two (Employers Liability Insurance) because Alaska is shown in Item 3.A. of the Information Page. THIS POLICY LIMITS COVERAGE FOR ATTORNEY FEES UNDER RULE 82 OF THE ALASKA RULES OF CIVIL PROCEDURE In any suit in Alaska in which we have a right or duty to defend an insured in addition to the limits of liability, our obligation under the applicable coverage to pay attorney fees taxable as costs against the Insured is limited as follows: Rule 82 of the Alaska Rules of Civil Procedure provides that if you are held liable, some or all of the attorney fees of the person making a claim against you must be paid by you. The amount that must be paid by you is determined by Rule 82. We provide coverage for attorney fees for which you are liable under Rule 82 subject to the following limitation: WE WILL NOT PAY THAT PORTION OF ANY ATTORNEY FEES THAT ARE IN EXCESS OF FEES CALCULATED BY APPLYING THE SCHEDULE IN RULE 82(b)(1) FOR CONTESTED CASES TO THE LIMIT OF LIABILITY OF THE APPLICABLE COVERAGE. This limitation means the potential costs that may be awarded against you as attorney fees may not be covered in full. You will have to pay any attorney fees not covered directly. For example, the attorney fees provided by the schedule in Civil Rule 82(b)(1) for contested cases are: 20% of the first $25,000 of a judgment or claim settlement. 10% of the amounts over $25,000 of a judgment or claim settlement. If a court awards a judgment against you in the amount of $125,000, in addition to the amount you would be liable under Rule 82(b)(1) for attorney fees of $15,000 calculated as follows: 20% of $ 25,000 $ 5,000 10% of $100,000 $10,000 Total Award $125,000 Total Attorney Fees $125,000 If the limit of liability of the applicable coverage is $100,000, we would pay $100,000 of the $125,000 award, and $12,500 Rule 82(b)(1) Attorney Fees, calculated as follows: 20% of $ 25,000 $ 5,000 10% of $ 75,000 $ 7,500 Total Limit of Liability $100,000 Total Attorney Fees Covered $12,500 You would be liable to pay, directly and without assistance, the remaining $25,000 in liability, plus the remaining $2,500 in attorney fees not covered by this policy. WC 54 03 01 COUNTERSIGNED BY ___________________________ (ED. 04-95) AUTHORIZED REPRESENTATIVE ALASKA NOTICE OF INSTALLMENT OPTION ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by the policy because Alaska is shown in Item 3.A. of the Information Page. If your annual estimated premium exceeds $2,000, you may elect to pay your premium on an installment basis of not fewer than two payments. Premiums paid by installment must be structured to reflect seasonal peaks in the basis of the premium. If you elect to pay your premium on an installment basis, we will issue an endorsement to show the installment schedule. WC 54 06 01 COUNTERSIGNED BY ___________________________ (ED. 8-91) AUTHORIZED REPRESENTATIVE IMPORTANT NOTICE TO EMPLOYERS DO YOU NEED USL&HW COVERAGE? DO YOU NEED OTHER FEDERAL COVERAGES? REVISED WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY All employers should carefully review their workers compensation coverage needs with their insurance professionals - your agent, broker, or insurer. The Workers Compensation and Employers Liability Policy does not provide federal coverages (such as United States Longshore and Harbor Workers' Compensation Act, Defense Base Act, Nonappropriated Fund Instrumentalities Act, Outer Continental Shelf Lands Act, or Black Lung Act) unless federal coverages are added by endorsement. Your old policy would normally exclude such federal coverages by means of standard amendatory endorsements unless you had requested the coverage when applying for or renewing your policy. Now the exclusions are part of your standard policy. Please note: You may also have had separate Workers Compensation and Employers Liability Policies - one that covered your Alaska Workers Compensation Act exposures and one that covered your federal act exposures. To secure a federal coverage under the Workers Compensation and Employers Liability Policy, you must specifically request the necessary federal coverages and then carefully review your policy when you receive it to make certain that an amendatory endorsement adds the federal coverage that you requested. WHAT IF AN EMPLOYER IS UNCERTAIN IF IT WILL NEED A FEDERAL ACT COVERAGE DURING THE POLICY TERM? Many employers such as construction contractors or oil services contractors will not know what contracts they will get during the policy term at the time a policy is purchased. Such an employer may not know if a job will involve exposure to federal acts such as USL&HW and/or Alaska Workers Compensation Act exposures. Other employers may have employees whose work falls in gray areas where the employer cannot predict which jurisdiction will apply should the employee be injured on the job. To avoid potential coverage gaps, these employers should have their policy endorsed to provide the needed federal act coverages on an "if any" basis. The employer would have to maintain payroll and job records as required by their insurer to document whether the employee's payroll should be classified Alaska Workers Compensation Act or a federal act such as USL&HW so that premium may be properly calculated; the rates are generally different. If federal exposures develop during the policy term, the employer's premium will be adjusted to reflect the additional exposure. However, an employer whose employees' work takes them in and out of federal and state act jurisdictions must have coverage for both exposures on an ongoing basis, not an "if any" basis. LWNAKNOTE (ED. 4-92) YOU AND YOUR WORKERS COMP POLICY LWNALASKA (ED. 4-92) The National Council on Compensation Insurance has filed revisions to the Workers Compensation and Employers Liability Insurance Policy (WCELIP) to become effective April 1, 1992, subject to state approval. Since the policy was last revised in 1984, numerous endorsements have been approved to clarity the WCELIP and to provide notice to the insured about the coverage provided by the policy. The current revisions incorporate the language of many standard endorsements directly into the policy, thus reducing paperwork and providing a more easily understood policy. Many standard endorsements pertain to the exclusion of coverage under federal laws. The WCELIP was designed to provide coverage under state workers compensation laws, and premium is determined on this basis. Coverage under federal workers compensation laws or specific federal acts was not contemplated. CHANGES TO POLICY In order to clarify the coverage grant of the WCELIP, General Section C has been amended to specify that federal coverage is not provided. The general definition of workers compensation now clearly excludes coverage under any federal workers or workmen's compensation law and any federal occupational disease law. Specifically excluded is coverage under the Longshore, Defense Base, Nonappropriated Fund Instrumentalities, Outer Continental Shelf Lands, Black Lung, and any other federal compensation statutory obligations. The standard endorsements used to exclude this coverge will be withdrawn with the approval of the revised policy. These changes to the policy will result in a simpler, more easily understood policy without change to the coverage provided. SPECIFIC REVISIONS The exclusion endorsements are incorporated into Part Two C of the WCELIP. Part Two C.7. has been amended to include the language of the standard Employers Liability Endorsement - WC 00 03 16. The purpose of this endorsement was to clarify that the acts listed within the endorsement fall outside common law negligence, the principal risk to be covered by employers liability insurance. Approval of the revised policy provides permission to withdraw Employers Liability Endorsement - WC 00 03 16. Part Two I. has been amended to include a provision that the insurer is not relieved of an obligation to pay because of the bankruptcy or insolvency of the insured. This provision ensures that an injured worker will receive payment under the Employers Liability section of the policy even if the employer is bankrupt or insolvent. Part Three A.2. has been amended to read, "If you begin work in any one of those states AFTER THE EFFECTIVE DATE OF THIS POLICY and are not insured or are not self-insured for such work, ALL PROVISIONS of the policy will apply as though that state were listed in Item 3.A. of the Information Page." The additions to this section were made to clarify that all notification and other provisions of the policy apply to Other States insurance. The insured should give notice of beginning work in a 3.C. state. Part Three A.4. has been added to the policy. This addition reads: IF YOU HAVE WORK ON THE EFFECTIVE DATE OF THIS POLICY In ANY STATE NOT LISTED IN ITEM 3.A. OF THE INFORMATION PAGE, COVERAGE WILL NOT BE AFFORDED FOR THAT STATE UNLESS WE ARE NOTIFIED WITHIN 30 DAYS. This addition is meant to strengthen the notification requirement so the insurer can accurately determine the extent of coverage. The insured will benefit because of more accurate reporting of Other States coverage. The inclusion of a 30-day time period was added at the request of agents and brokers who expressed concern that the insured might not be in a position to provide notice prior to beginning work. AMENDATORY ENDORSEMENT In order to provide for the interim period in which the policy revisions will be approved in some jurisdictions and not in others, an Amendatory Endorsement - WC 00 03 18 will be used. This endorsement modifies the old policy to include all the revisions. By utilizing a schedule to indicate the states in which the Amendatory Endorsement is effective, it is possible to issue only one policy even if the insured has operations in states with differing approval statuses. The clear, concise and condensed revisions to the Workers Compensation and Employers Liability Insurance Policy - WC 00 00 00 A have been filed nationwide with a proposed effective date of April 1, 1992. These revisions are expected to benefit insured and insurer alike. LWNALASKA (ED. 4-92) TABLE OF ENDORSEMENT CHANGES MODIFIED WITHDRAWN Defense Base Act Coverage Federal Employers' Liability Endorsement - WC 00 01 01 A Act Exclusion Endorsement - WC 00 01 05 Longshore and Harbor Workers' Compensation Act Longshore and Harbor Workers' Compensation Act Coverage Endorsement - WC 00 01 06 A Exclusion Endorsement - WC 00 01 07 A Nonappropriated Funds Instrumentalities Act Migrant and Seasonal Agricultural Worker Protection Coverage Endorsement - WC 00 01 08 A Act Exclusion Endorsement - WC 00 01 10 Outer Continental Shelf Lands Act Coverage Maritime Exclusion Endorsement - WC 00 01 09 A Endorsement - WC 00 02 02 Maritime Coverage Employers Liability Insurance Endorsement - WC 00 02 01 A Endorsement - WC 00 03 16 Employers Liability Coverage Endorsement - WC 00 03 03 B (Advisory) Ohio Employers Liability Coverage Endorsement - WC 34 03 01 B (Advisory) (Ohio only) LWNALASKA (ED. 4-92) INSURED'S COPY The questions most frequently asked by insureds are answered below: Q. How will I be able to obtain coverage under the Longshore and Harbor Workers' Compensation Act and other federal acts? A. The WCELIP was designed to provide coverage under state workers compensation laws, and premium is determined on this basis. Coverage under federal workers compensation laws on specific federal acts was not contemplated. Previously, exclusion endorsements were attached to policies to clarify the lack of coverage. Employers who wish to purchase coverage under a federal act may continue to do so by means of a coverage endorsement. This coverage is still available to you on the same basis as if was prior to policy revision. Q. How does Part Three work? A. Part Three provides that if there are other states shown in Item 3.C. of the Information Page and you begin work in those states, the policy applies as though that state were listed in Item 3.A. Only if you begin work in a 3.C. state will premium develop. NOTIFY YOUR AGENT OR INSURER IMMEDIATELY IF YOU BEGIN WORK IN A STATE LISTED IN ITEM 3.C. Q. How has Part Three coverage changed and what are my obligations, if any? A. Part Three (Other States Coverage) has been changed to require notice to the insurer of work you have on the effective date of the policy. You have thirty days to provide this notice. If you begin work after the effective date of this policy and are not insured or self-insured for such work, all provisions of the policy will apply as though the state was listed in Item 3.A. of the Information Page. Q. What if I have work in states that have approved the revisions and in states that have not approved? Will I need two policies? A. One policy will be issued, if you currently have one policy. The unrevised policy will be issued with an endorsement (Amendatory Endorsement - WC 00 03 18). This endorsement will convert the policy to the revised version in those states that are listed in the schedule. If you have additional questions, please contact your agent or your insurance company. LWNALASKA (ED. 4-92) INSURED'S COPY ARKANSAS NOTICE TO POLICYHOLDERS THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA ____________ is required by law to provide its policyholders with certain accident prevention services as required by Arkansas Code Ann. Section 1l-9-409(4)(c) at no additional cost. If you would like more information call AIG Consultants at the location below. If you have any questions about this requirement, call the Health and Safety Division, Arkansas Workers' Compensation Commission at 1-800-622-4472. For your consideration, we have the services of AIG Consultants, Inc., a professional engineering company with established experience and expertise. AIG Consultants, Inc. can address a significant range of commercial problems and advise and asist you in recognizing and solving existing potential problems for accidents and occupational health hazards. AIG Consultants, Inc. has been operating for more than 15 years and when utilized has responded to individual client's problems to provide efficient consultative services by qualified safety consultants. These safety and health consultative services consist of, but are not limited to, the following: 1) A survey of the safety performance of the risk and its activities. 2) An appraisal of the mechanical hazards, materials handling, unsafe work methods and hazardous processes. 3) Advice and assistance in the detection of occupational health training programs. 4) Assistance to the risk with employee safety and health training programs. 5) Recommendations for appropriate corrective action as result of any survey. 6) Assistance in the development of a safety and health program. You can contact AIG consultants, Inc. at 1-800-221-0651. 59471 WC COUNTERSIGNED BY ___________________________ (ED. 01-94) AUTHORIZED REPRESENTATIVE INSURED'S COPY ARKANSAS AMENDATORY ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 lssued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by the policy because Arkansas is shown in Item 3.A. of the Information Page. PART TWO-EMPLOYERS LIABILLTY INSURANCE C. EXCLUSIONS 2. is replaced by: punitive or exemplary damages because of bodily injury to an employee employed in violation of law; punitive or exemplary damages are defined by Arkansas Bulletin No. 4-82 as those damages which are imposed to punish a wrongdoer and to deter others from similar conduct; PART SIX-CONDITIONS D. CANCELATION is replaced by: 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancelation is to take effect. 2. We may cancel this policy. If we cancel because you fail to pay all premium when due, we will mail or deliver to you and to the Arkansas Workers Compensation Commission not less than 10 days advance written notice stating when the cancelation is to take effect. If we cancel for any other reason, we will mail or deliver to you and to the Arkansas Workers Compensation Commission not less than 30 days advance written notice stating when the cancelation is to take effect. Mailing notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient notice. 3. The policy period will end on the day and hour stated in the cancelation notice. WC 03 06 01 A COUNTERSIGNED BY_______________________________ (ED. 04-92) AUTHORIZED REPRESENTATIVE INSURED'S COPY ENDORSEMENT This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: WC 217-79-40 Issued to: OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA IMPORTANT NOTICE TO POLICYHOLDERS In the event you need to contact someone about this policy for any reason please contact your agent. If you have additional questions you may contact the insurance company issuing this policy at the following address and telephone number: INS CO OF THE STATE OF PENN 70 Pine Street, New York City, N.Y. 10270 Telephone 1-212-770-7000 CENTURY FINANCIAL SERVICES 185 N W SPANISH RIVER BLVD 170 POB 811088 If we at INS CO OF THE STATE OF PENN fail to provide you with reasonable and adequate service, you should feel free to contact: Arkansas Insurance Department Consumer Services Division 400 University Tower Building 5TH FLOOR Little Rock, Arkansas 72204 (501) 686-2945 (800) 852-5494 _______________________________________ Authorized Representative Issue Date: 04/10/97 LWNINPHA INSURED'S COPY CONNECTICUT APPLICATION OF WORKERS COMPENSATION INSURANCE ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following 'attaching clause' need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by Part One (Workers Compensation Insurance) because Connecticut is shown in Item 3.A. of the Information Page. Section A, "How This Insurance Applies, of Part One, "Workers Compensation Insurance," is amended to read as follows: This workers compensation insurance applies to injury by accident or injury by disease. Injury includes resulting death. 1) Injury by accident must occur during the policy period. 2) Injury by disease must be caused or aggravated by exposure during the policy period to conditions of your employment. ______________________________________________ WC 06 03 01 COUNTERSIGNED BY (ED. 4-84) AUTHORIZED REPRESENTATIVE INSURED'S COPY CONNECTICUT WORKERS COMPENSATION FUNDS COVERAGE ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by Part One (Workers Compensation Insurance) because Connecticut is shown in Item 3.A. of the Information Page. The amount shown on the Information Page for the Connecticut workers compensation fund assessments is required of you under Sections 31-283b (Employers' contribution to fund), 31-283h (Division of worker education), 31-345 (Certificate of solvency; assessments; overpayments) and 31-354 (Assessments and contributions) of the Connecticut General Statutes. As provided in Section 31-284(c) (Employer rights and liabilities), we will pay these assessments to the Connecticut State Treasurer. The purpose of the assessment is to finance the Rehabilitation Division, the Division of Worker Education, the expenses of administering the law and the Second Injury and Compensation Assurance Fund. _____________________________________________ C 06 03 03A COUNTERSIGNED BY (ED. 01-91) AUTHORIZED REPRESENTATIVE INSURED'S COPY CONNECTICUT WORKERS COMPENSATION FUNDS ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by Part One (Workers Compensation Insurance) because Connecticut is shown in Item 3.A. of the Information Page. The amount shown on the Information Page for the Connecticut workers compensation fund assessment is required of you under Section 31-345 (Certificate of solvency; assessments; overpayments) of the Connecticut General Statutes. As provided in Section 31-284(c) (Employer rights and liabilities), we will pay these assessments to the Connecticut State Treasurer. The purpose of the assessment is to finance the expenses of administering the law. THE AMOUNT SHOWN ON THE INFORMATION PAGE FOR THE CONNECTICUT SECOND INJURY FUND SURCHARGE IS REQUIRED OF YOU UNDER CONNECTICUT REGULATIONS TO FINANCE THE CONNECTICUT SECOND INJURY FUND. WE WILL PAY THIS SURCHARGE TO THE CONNECTICUT STATE TREASURER. ______________________________________________ WC 06 03 03 B COUNTERSIGNED BY (ED. 04-96) AUTHORIZED REPRESENTATIVE INSURED'S COPY CONNECTICUT RETROSPECTIVE PREMIUM SUPPLEMENTAL ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to: OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement changes the Retrospective Premium Endorsement identified in the Schedule. The change applies only to the premium charged because Connecticut is shown in Item 3.A. of the Information Page. 1. Connecticut standard premium does not include the non-ratable portion of the premium for classifications shown in our manuals as having a specific disease element. The non-ratable portion is a percentage of the premium otherwise determined for the classification. The classifications with a specific disease element and the corresponding non-ratable retrospective percentage are shown in the Schedule. 2. Incurred losses do not include workers compensation pneumoconiosis disease losses to employees assigned to a classification that includes a specific disease element. Schedule Retrospective Premium Endorsement: 2. CLASSIFICATION NON-RATABLE PERCENTAGE WC 06 05 01 (ED. 04-84) ___________________________________________ COUNTERSIGNED BY AUTHORIZED REPRESENTATIVE INSURED'S COPY NOTICE TO POLICYHOLDERS Our medical services provider, Physicians Health Services, Inc.- (PHS) is currently in the process of obtaining the necessary authorization to act as a Managed Care Organization under the Connecticut Workers Compensation Law. Once PHS obtains authorization, the Connecticut Workers' Compensation Commission must approve PHS' managed care plan as it applies to your employees. In the meantime, your employees retain all of their current rights under the Connecticut Workers Compensation laws until authorization is obtained for PHS to act as a Managed Care Organization for your employees. This includes the right to choose a physician or other medical provider not affiliated with PHS for all injuries that occur before PHS obtains authorization. Please make certain that your Employees are made aware of this. Once authorization is obtained, employees must select a physician or medical services provider affiliated with PHS for treatment of injuries occurring after the authorization date, in order to collect workers' compensation benefits. We will notify you as soon as PHS authorization as a Managed Care Organization is obtained. Please continue to use PHS as previously instructed. _____________________________________________ LWNNPAH COUNTERSIGNED BY (ED. 05-95) AUTHORIZED REPRESENTATIVE INSURED'S COPY DISTRICT OF COLUMBIA CANCELLATION ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching claus" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by the policy because District of Columbia is shown in Item 3.A. of the Information Page. The Cancellation Condition of the policy is replaced by this Condition: D. CANCELLATION 1. You may cancel this policy. You must mail or deliver advance notice to us stating when the cancellation is to take effect. 2. We may cancel this policy. We will mail or deliver to you and the Mayor not less than 30 days advance written notice stating when the cancellation is to take effect. Mailing this notice to you at your mailing address last known to us will be sufficient to prove notice. 3. The policy period will end on the day and hour stated in the cancellation notice. ___________________________________________ WC 08 06 01 COUNTERSIGNED BY (ED. 4-84) AUTHORIZED REPRESENTATIVE INSURED'S COPY FLORIDA EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by the policy because Florida is shown in Item 3.A. of the Information Page. A. The premium for the policy will be adjusted by an experience rating modification factor. The factor was not available when the policy was issued. The factor, if any, shown on the Information Page is an estimate. We will issue an endorsement to show the proper factor, if different from the factor shown, when it is calculated. B. If the factor is an increase over that shown on the Information Page, it will apply as of the policy effective date; or if the anniversary rating date is different from the policy effective date it will apply as of the anniversary rating date. Your premium will be calculated: 1. Retroactively to the effective date of the policy or to the anniversary rating date if the adjustment is within the first 90 days of the policy period or the anniversary rating date; 2. On a pro rata basis from the date we endorsed the policy if the adjustment is more than 90 days after the effective date of the policy or the anniversary rating date. The adjustment will be retroactive to the effective date of the policy period or to the anniversary rating date when: a. The change is experience modification is the result of a revision in your classifications; b. The delay in the calculation of the experience modification is due to your failure to make available all your records for examination and audit as provided in Part Five-G (Audit) of the policy. C. If the factor is a decrease from that shown on the Information Page, it will apply retroactively to the policy effective date or the anniversary rating date if different from the policy effective date. __________________________________________ WC 09 04 02 COUNTERSIGNED BY (ED. 10-88) AUTHORIZED REPRESENTATIVE INSURED'S COPY GEORGIA CANCELATION, NONRENEWAL AND CHANGE ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by the Policy because Georgia is shown in Item 3.A. of the Information Page. The CANCELATION Condition of the policy is replaced by this Condition: D. CANCELATION, NONRENEWAL AND CHANGE 1. You may cancel this policy. You must mail or deliver advance notice to us stating when the cancelation is to take effect, subject to the following: a. If only your interest is affected, the effective date of cancelation will be the later of the date we receive notice from you or the date specified in the notice. b. If by statute, regulation or contract this policy may not be canceled unless notice is given to a governmental agency or other third party, we will mail or deliver at least 10 days notice to you and the third party as soon as practicable after receiving your request for cancelation. Our notice will state the effective date of cancelation, which will be the later of the following: 1) 10 days from the date of mailing or delivering our notice, or 2) The effective date of cancelation stated in your notice to us. 2. We may cancel or nonrenew this policy. We must mail or deliver notice at least 10 days before the effective date of cancelation if this policy has been in effect less than 60 days or if we cancel for nonpayment of premium. If this policy has been in effect 60 or more days and we cancel for a reason other than nonpayment of premium, or if we nonrenew this policy, we must send to you a notice of cancelation or nonrenewal by certified mail, return receipt requested, to your last address of record at least 75 days prior to the effective date of cancelation or nonrenewal. 3. If we increase current policy premium by more than 15% (other than any increase due to change in risk, exposure or experience modification or resulting from an audit of auditable coverages), limit or restrict coverage, we must mail by first class mail or deliver a notice of our action (including dollar amount of any increase in renewal premium more than 15%) to you at the last mailing address of record at least 45 days before the expiration date of this policy. 4. The policy period will end on the day and hour stated in the cancelation notice except as provided for above. WC 10 06 01 A ______________________________________________ (ED. 04-93) COUNTERSIGNED BY AUTHORIZED REPRESENTATIVE INSURED'S COPY ILLINOIS AMENDATORY ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. RM 12:01 AM 01/01/97 WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by the policy because Illinois is shown in Item 3.A. of the Information Page. Part Six (Conditions), Condition A. Inspection, Condition D. Cancellation and Condition E. Sole Representative of the policy are replaced by these four Conditions. INSPECTION We have the right, but are not obliged, to inspect your workplaces at any time. Our inspections are not safety inspections. They relate only to the insurability of the workplaces and the premiums to be charged. We may give you reports on the conditions we find. We may also recommend changes. While they may help reduce losses, we do not undertake to perform the duty of any person to provide for the health or safety of your employees or the public. We do not warrant that your workplaces are safe or healthful or that they comply with laws, regulations, codes or standards. The National Council on Compensation Insurance has the same rights we have under this provision. CANCELATION You may cancel this policy. You will mail or deliver advance written notice to us, stating when the cancelation is to take effect. 2. We may cancel this policy. We will mail to each named insured and to the broker or the agent of record advance written notice stating when the cancelation is to take effect. 3. If we cancel because you do not pay all premium when due, we will mail the notice of cancelation at least ten days before the cancelation is to take effect. If we cancel for any other reason, we will mail the notice: a. at least 30 days before the cancelation is to take effect if the policy has been in force for 60 days or less; b. at least 60 days before the cancelation is to take effect if the policy has been in force for more than 60 days. 4. If this policy has been in effect for 60 days or more, we may cancel only for one of the following reasons: a. Nonpayment of premium. b. The policy was issued because of a material misrepresentation. c. You violated any of the material terms and conditions of the policy. d. There are unfavorable underwriting factors, specific to you, that were not present when the policy took effect. e. The Director has determined that we no longer have adequate reinsurance to meet our needs. f. The Director has determined that continuation of coverage could place us in violation of the laws of Illinois. 5. Our notice of cancelation will state our reasons for cancelling. Page 1 of 2 WC 12 06 01 B (ED. 6-89) INSURED'S COPY 6. The policy period will end on the day and hour stated in the cancelation notice. NONRENEWAL We may elect not to renew the policy. We will mail to each named insured and to the broker or the agent of record not less than 60 days notice stating when the nonrenewal will take effect. If we do not give 60 days but instead give between 31 and 60 days, the policy will automatically be extended for 60 days. If we fail to give 31 days notice, the policy will automatically be extended for one year. Mailing that notice to you at your last known mailing address will be sufficient to prove notice. 2. Our notice of nonrenewal will state our reasons for not renewing. 3. If we fail to provide the notice of nonrenewal as required, the policy will still terminate on its expiration date if: a. We show you a willingness to renew the policy, or; b. You notify us or the agent or broker who procured this policy that you do not want the policy renewed, or; c. You fail to pay all premiums when due; or d. You obtain other insurance as a replacement of the policy. SOLE REPRESENTATIVE The insured first named in Item 1 of the Information Page will act on behalf of all insureds to change this policy, receive return premium or to give us notice of cancelation. Part Five (Premium), Section G. Audit is replaced by this Section. AUDIT You will let us examine and audit all your records that relate to this policy. These records include ledgers, journals, registers, vouchers, contracts, tax reports, payroll and disbursement records, and programs for storing and retrieving data. We may conduct the audits during regular business hours during the policy period and within three years after the policy ends. Information developed by audit will be used to determine final premium. The National Council on Compensation Insurance has the same rights we have under this provision. ____________________________________________ WC 12 06 01 B COUNTERSIGNED BY (ED. 6-89) AUTHORIZED REPRESENTATIVE Page 2 of 2 INSURED'S COPY NOTICE TO POLICYHOLDERS We are here to serve you... As our policyholder, your satisfaction is very important to us. If you have a question about your policy, if you need assistance with a problem, or if you have a claim, you should first contact your insurance agent or us at (212) 770-7195 by calling collect between the hours of 8:30 a.m. - 5:00 p.m. Eastern Time. Should you have a valid claim, we fully expect to provide a fair settlement in a timely fashion. Should you feel you are not being treated fairly with respect to a claim, you may contact the Indiana Department of Insurance with your complaint. To contact the Department, write or call: Consumer Services Division Indiana Department of Insurance 311 West Washington Street, Suite 300 Indianapolis, IN 46204-2787 317-232-2395 or 1-800-622-4461 6295SWC (Ed. 06-95) INSURED'S COPY NOTICE TO POLICYHOLDERS We are here to serve you... As our policyholder, your satisfaction is very important to us. Should you have a valid claim, we fully expect to provide a fair settlement in a timely fashion.. If you are not satisfied... Should you feel you are not being treated fairly, we want you to know you may contact the Indiana Department of Insurance with your complaint and seek assistance from the governmental agency that regulates insurance. To contact the Department, write or call: Public Information/Market Conduct Indiana Department of Insurance 311 West Washington Street, Suite 300 Indianapolis, IN 46204-2787 Consumer Hotline: 1-800-622-4461 In the Indianapolis Area: 1-317-232-2395 LWNINPOL INSURED'S COPY KENTUCKY ADDENDUM TO APPLICATION POLICYHOLDER'S NOTICE This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. ______________________________________________ 60713WC COUNTERSIGNED BY (ED. 07-94) AUTHORIZED REPRESENTATIVE INSURED'S COPY NOTICE TO INSUREDS TAX AND ASSESSMENT-KENTUCKY his endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA The Kentucky Insurance Department does not consider taxes and assessments a part of Workers' Compensation Insurance Rates. Therefore, the monies charged the insured for taxes and assessments under the Kentucky Workers' Compensation Law, pursuant to KRS 342.122 and 342.445 as now or hereafter amended, are not included as premium under the policy. As a result, the company acts as a tax collector with respect to taxes and assessments and is required under the Workers' Compensation Law to collect and remit the taxes and assessments to the Kentucky Commissioner of Revenue. Effective 01/01/96, a tax and assessment rate of 9.00 % is applicable to new and renewal policies. The tax and assessment due is $ SEE KENTUCKY SCHEDULE OF OPERATIONS. _______________________________________________ WC 00 02 92 COUNTERSIGNED BY (ED. 10-84) AUTHORIZED REPRESENTATIVE INSURED'S COPY LOUISIANA PUNITIVE DAMAGES ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different late is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by the policy because Louisiana is shown in Item 3.A. of the Information Page. Part Two--Employers Liability Insurance of the policy is changed by removing the following: C. EXCLUSIONS 2. punitive or exemplary damages because of bodily injury to an employee employed in violation of law. ______________________________________________ WC 17 03 02 COUNTERSIGNED BY (ED. 9-90) AUTHORIZED REPRESENTATIVE INSURED'S COPY LOUISIANA AMENDATORY ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy UNLESS a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by the Policy because Louisiana is shown in Item 3.A. of the Information Page The CANCELATION Condition of the policy is replaced by this Condition: D. CANCELATION 1. Written notice of such cancelation must be actually delivered or mailed to the insured or to his representative in charge of the subject of the insurance not less than twenty days prior to the effective date of the cancelation except where termination of coverage is for nonpayment of premium. 2. Upon the written request of the named insured, the insurer shall provide to the insured in writing the reasons for cancelation of the policy. There shall be no liability on the part of and no cause of action of any nature shall arise against any insurer or its agents, employees, or representatives for any action taken by them to provide the reasons for cancelation as required by the Subparagraph. 3. Where written notice of cancelation or nonrenewal is required and the insurer elects to mail the notice, the running of the time period between the date of mailing and the effective date of termination of coverage shall commence upon the date of mailing. 4. Any policy may be canceled by the company at any time during the policy for failure to pay any premium when due whether such premium is payable directly to the company or its agent or indirectly under a premium finance plan or extension of credit, by mailing or delivering to the insured written notice stating when, not less than ten days thereafter, such cancelation shall be effective. 5. The mailing of any such notice shall be effected by depositing it in a sealed envelope, directed to the addressee at his last address as known to the insurer or as shown by the insurer's records, with proper prepaid postage affixed, in a letter depository of the United States Post Office. The insurer shall retain in its records any such item so mailed, together with its envelope, which was returned by the Post Office upon failure to find or deliver the mailing to the addressee. 6. The affidavit of the individual making or supervising such a mailing shall constitute prima facie evidence of such facts of the mailing as are therein affirmed. 7. The portion of any premium paid to the insurer on account of the policy, including unearned commission, unearned because of the cancelation and in amount as computed on the pro rata basis, must be actually paid to the insured or other person entitled thereto as shown by the policy or by any endorsement thereon, or be mailed to the insured or such person as soon as practicable following such cancelation. Any such payment may be made by cash, or by check, bank draft, or money order. ______________________________________________ WC 17 06 01 COUNTERSIGNED BY (ED. I 1 -92) AUTHORIZED REPRESENTATIVE INSURED'S COPY LOUISIANA COST CONTAINMENT ACT ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a Different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by the policy because Louisiana is shown in Item 3.A. of the Information Page. You may be eligible for a two (2) percent reduction in your premium if you attend a cost containment meeting conducted by the Occupational, Safety and Health Administration (OSHA) Section of the Office of Workers Compensation Administration. In order for you to receive the reduction, you must submit to us a certificate of attendance from the OSHA Section. The reduction will APPLY for a period of one year and will be applied to the policy becoming effective after the date you attended the cost containment meeting. You may also be eligible for an additional five (5) percent reduction in your premium if you have attended a cost containment meeting and have subsequently satisfactorily implemented an occupational safety and health program prescribed by the OSHA Section. In order for you to receive the reduction, you must submit to us a Certificate of Satisfactory Implementation of Occupational, Safety and Health Ptogram from the OSHA Section. The reduction will apply for a period of one year and will be applied to the policy becoming effective after the date of your certification. WC 17 06 02 A _______________________________________________ (ED. 02-96) COUNTERSIGNED BY AUTHORIZED REPRESENTATIVE INSURED'S COPY MASSACHUSETTS LIMITS OF LIABILITY ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by Part Two (Employers Liability Insurance) because Massachusetts is listed in Item 3.A. of the Information page. Our liability to you under Section 25 of Chapter 152 of the General Laws of Massachusetts is not subject to the limit of liability that applies to Part Two (Employers Liability Insurance). _______________________________________________ WC 20 03 01 COUNTERSIGNED BY (ED. 4-84) AUTHORIZED REPRESENTATIVE INSURED'S COPY MASSACHUSETTS-ASSESSMENT CHARGE This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA Massachusetts General Laws, Chapter 152, Section 65, as amended by Chapter 572 of the Acts of 1985, establishes a workers compensation special fund and a workers compensation trust fund. On behalf of the Department of Industrial Accidents (DIA), the insurance company providing workers compensation coverage is required to bill and collect an assessment charge covering the special and trust funds from insured employers and remit the amounts collected to the State Treasury. The assessment charge which is determined by applying a rate (subject to annual change) to the standard premium developed under your policy, is shown as a separate item on the Information page of the policy. The rate may be different for private employers and for the Commonwealth and its political subdivisions. The income derived from the assessment charge will be used to fund the operating expenses of the DIA and to fund certain employee benefits as described in Chapter 152. ______________________________________________ WC 20 03 02 COUNTERSIGNED BY (ED. 5-86) AUTHORIZED REPRESENTATIVE INSURED'S COPY MASSACHUSETTS NOTICE TO POLICYHOLDER ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by the policy because Massachusetts is shown in Item 3.A. of the Information Page. 1. Rates and Premium The policy contains rates and classifications that apply to your type of business. If you have any questions regarding the rates or classifications, please contact your agent or us. You may obtain pertinent rating information by submitting a written request to us at our address shown on this endorsement. We may require you to pay a reasonable charge for furnishing the information. You may also submit request for a review of the method by which your classification, rates or premiums were determined. If you are not satisfied with the results of the review, you may appeal to the Commissioner of Insurance at the address shown in this endorsement. 2. Reserves or Settlements You may request a loss run which contains reserve and settlement information for claims that relate to the premium for this policy. Such a request must be in writing and should be sent to our address shown on this endorsement. We will provide you with information within thirty (30) days of receipt of your request, and at reasonable intervals thereafter. If you have any questions or believe that we set unreasonable reserves or made unreasonable settlements that affected your premiums or losses, you may make a written request through your agent or directly to us for a meeting with our company representative. If you are not satisfied with the results of the meeting, you may make a written appeal to the Insurance Commissioner at the address shown on the endorsement. Addresses Commissioner of Insurance Company Address Division of Insurance Department of Banking and Insurance 470 Atlantic Avenue Boston, MA 02210-2223 ____________________________________________ WC 20 03 03 A COUNTERSIGNED BY (ED. 8-95) AUTHORIZED REPRESENTATIVE INSURED'S COPY MASSACHUSETTS CANCELATION ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by the policy because Massachusetts is shown in Item 3.A. of the Information Page. The CANCELATION Condition of the policy is replaced by the following: CANCELATION 1. You may cancel this policy by mailing or delivering to us advance written notice requesting cancelation. Such cancelation shall not be effective until ten days after written notice is given by us to The Workers' Compensation Rating and Inspection Bureau of Massachusetts (Bureau), or until notice has been received by the Bureau that you have secured insurance from another insurance company, whichever occurs first. 2. We may cancel this policy only if based on one or more of the following reasons: (I) nonpayment of premium; (II) fraud or material misrepresentation affecting your policy; or (III) a substantial increase in the hazard insured against. Such cancelation shall not be effective until ten days after written notice is given by us to you and The Workers' Compensation Rating and Inspection Bureau of Massachusetts (Bureau), or until notice has been received by the Bureau that you have secured insurance from another insurance company, whichever occurs first. 3. Any of these provisions that conflict with the law that controls the cancelation of this insurance policy is changed by this statement to comply with the law. _____________________________________________ WC 20 06 01 COUNTERSIGNED BY (ED. 6-92) AUTHORIZED REPRESENTATIVE INSURED'S COPY MICHIGAN NOTICE TO POLICYHOLDER ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by the policy because Michigan is shown in Item 3.A. of the Information Page. 1. RATES AND PREMIUM The policy contains rates and classifications that apply to your type of business. If you have any questions regarding the rates or classifications, please contact us or your agent. You may obtain pertinent rating information by submitting a written request to us at our address shown on this endorsement. We may require you to pay a reasonable charge for furnishing the information. You may also submit a written request for a review of the method by which your rates and premiums were determined. If you are not satisfied with the results of the review, you may appeal to the Commissioner of Insurance at the address shown in this endorsement. 2. PAYROLL AUDITS You may request a payroll audit once each calendar year. Your request must be in writing sent to our address shown in this endorsement. You must state that you believe your payroll expenditures have changed by 20% or more, and you must state the reasons for that belief. We will complete the audit within 120 days of receipt of your request if you provide us with all information we need to perform the audit. 3. RESERVES OR REDEMPTION You may request reserve and redemption information that relates to the premium for this policy. Your request must be in writing sent to our address shown in this endorsement. We will provide you with that information within thirty (30) days of receipt of your request. If you believe that the policy premiums are excessive because we set unreasonable reserves or because of the unreasonable redemption of a claim, you may request a meeting with our management representative. Your request must be in writing sent to our address shown in this endorsement. If you are not satisfied with the results of the meeting, you may appeal to the Insurance Commissioner at the address shown in this endorsement. Addresses Commissioner of Insurance Company Address Michigan Insurance Bureau Department of Licensing & Regulation P.O. Box 30220 Lansing, MI 48909 _____________________________________________ WC 21 03 03 COUNTERSIGNED BY (ED. 4-84) AUTHORIZED REPRESENTATIVE INSURED'S COPY MICHIGAN LAW ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by the policy because Michigan is shown in Item 3.A. of the Information Page. Michigan law requires that we attach this paragraph to your policy in the language specified by the statute. To help you understand the paragraph, the following defenitions are added: 1. We are "the insurer issuing this policy". 2. You are "the insured employer". 3. "Michigan workmen's compensation act" means the Workers' Disability Compensation Act of 1969. 4. "Workmen's compensation" means workers' compensation. 5. "The bureau of workmen's compensation" means the Bureau of Workers' Disability Compensation. Notwithstanding any language elsewhere contained in this contract or policy of insurance, the accident fund or the insurer issuing this policy hereby con- tracts and agrees with the insured employer: COMPENSATION: (a) That it will pay to the persons that may become entitled thereto all workmen's compensation for which the insured employer may become liable under the provisions of the Michigan workmen's compensation act for all compensable injuries or compensable occupational diseases happening to his employees during the life of this contract or policy; MEDICAL SERVICES: (b) That it will furnish or cause to be furnished to all employees of the employer all reasonable medical, surgical, and hospital services and medicines when they are needed which the employer may be obligated to furnish or cause to be furnished to his employees under the provisions of the Michigan workmen's compensation act and that it will pay to the persons entitled thereto for all such services and medicines when they are needed for all compensable injuries or compensable occupational disease happening to his employees during the life of this contract or policy; REHABILITATION SERVICES: (c) That it will furnish or cause to be furnished such rehabilitation services for which the insured employer may become liable to furnish or cause to be furnished under the provisions of the Michigan workmen's compensation act for all compensable injuries or compensable occupational disease happening to his employees during the life of this contract or policy; WC21 06 01 (Ed. 4-84) Page 1 of 2 INSURED'S COPY FUNERAL EXPENSES: (d) That it will pay or cause to be paid the reasonable expense of the last sickness and burial of all employees whose death are caused by compensable injuries or compensable occupational diseases happening during the life of this contract or policy and arising out of and in the course of their employment with the employer, which the employer may be obligated to pay under the provisions of the Michigan workmen's compensation act; SCOPE OF CONTRACT: (e) That this insurance contract or policy shall for all purposes be held and deemed to cover all the businesses the said employer is engaged in at the time of the issuance of this contract or policy and all other businesses, if any, the employer may engage in during the life thereof, and all employees the employer may employ in any if his businesses during the period covered by this policy; OBLIGATIONS ASSUMED: (f) That this hereby assumes all obligations imposed upon the employer by his acceptance of the Michigan workmen's compensation act, as far as the payment of ompensation, death benefits, medical, surgical, hospital care or medicine and rehabilitation services is concerned; TERMINATION NOTICE: (g) That it will file with the bureau of workmen's compensation at Lansing, Michigan, at least 20 days before taking effect of any termination or cancellation of this contract or policy, a notice giving the date at which it is proposed to terminate or cancel this contract or policy; and that any termination of this policy shall not be effective as far as the employees of the insured employer are concerned until 20 days after notice of porposed termination or cancellation is received by the bureau of workmen's compensation; CONFLICTING PROVISIONS: (h) That all the provisions of this contract, if any which are not in harmony with this paragraph are to be construed as modified hereby and all conditions and limitations in the policy, if any, conflicting herewith are hereby made null and void. _________________________________________ WC 21 06 01 COUNTERSIGNED BY (ED. 4-84) AUTHORIZED REPRESENTATIVE Page 2 of 2 INSURED'S COPY MINNESOTA CANCELATION AND NONRENEWAL ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided because Minnesota is shown in Item 3.A. of the Information Page. CANCELATION OF A NEW POLICY If this policy is a new policy and has been in effect for fewer than 90 days, we may cancel for any reason by giving you notice at least 30 days before the effective date of cancelation. CANCELATION OF OTHER POLICIES If this policy has been in effect for 90 days or more, or if it is a renewal of a policy we issued, we may cancel FOR ONE OR MORE of the following reasons: 1. Nonpayment of premium; 2. Misrepresentation or fraud made by you or with your knowledge in obtaining the policy or in pursuing a claim under the policy; 3. An act or omission by you that substantially increases or changes the risk insured; Refusal by you to eliminate known conditions that increase the potential for loss after notification by us that the condition must be removed; 5. Substantial change in the risk assumed, except to the extent that we should reasonably have foreseen the change or contemplated the risk in writing this policy; 6. Loss of reinsurance by us which provided coverage to us for a significant amount of the underlying risk insured. Any notice of cancelation pursuant to this item shall advise you that you have 10 days from the date of receipt of the notice to appeal the cancelation to the commissioner of commerce and that the commissioner will render a decision as to whether the cancelation is justified because of the loss of reinsurance within 5 business days after receipt of the appeal; 7. A determination by the commissioner that the continuation of the policy could place us in violation of the Minnesota insurance laws; or 8. Nonpayment of dues to an association or organization, other than an insurance association or organization, where payment of dues is a prerequisite to your obtaining or continuing this policy. This item shall not apply to persons who are retired at 62 years of age or older or who are disabled according to Social Security standards. If we cancel your policy for any of the reasons listed in (1) through (8), we will give notice at least: 1. 30 days before the effective date of cancelation, if we cancel for nonpayment of premium; or 2. 60 days before the effective date, if we cancel for a reason described in (2) through (8) above. WC 22 06 01 A (ED. 10-92) 1 OF 2 INSURED'S COPY NOTICE OF CANCELATION Any notice of cancelation under this endorsement shall be in writing and shall be sent by first class mail or delivered to you and any agent, to the last mailing addresses known to us. A cancelation notice for nonpayment of premium shall state the amount of premium due and the due date, and shall state the effect of nonpayment by the due date. Cancelation shall not be effective if payment of the amount due is made prior to the effective date of cancelation in the notice. A cancelation notice for some other reason shall state the specific reason for cancelation and shall state the effective date of cancelation. The policy will end on that date. REFUNDS DUE YOU If this policy is canceled, we will send you any premium refund due. If we cancel, the refund will be pro rata. If you cancel, the refund may be less than pro rata. The cancelation will be effective even if we have not made or offered a refund. NONRENEWAL OF YOUR POLICY Any notice of nonrenewal shall be in writing and shall be sent by first class mail, or delivered to you and any agent, to the last mailing addresses known to us, at least 60 days before the expiration date. We need not mail or deliver this nonrenewal notice if you have: 1. Insured elsewhere; 2. Accepted replacement coverage; or 3. Requested or agreed not to renew this policy. ________________________________________________ WC 22 06 01 A COUNTERSIGNED BY (ED. 10-92) AUTHORIZED REPRESENTATIVE 2 of 2 INSURED'S COPY NOTICE CONCERNING POLICYHOLDER RIGHTS IN AN INSOLVENCY UNDER THE MINNESOTA INSURANCE GUARANTY ASSOCIATION LAW This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA If the Insurer who issued your property and casualty or liability insurance policy (includes homeowners and automobile insurance) becomes impaired or insolvent you are entitled to compensation for your policy from the assets of the insurer. The amount you recover will depend on the financial condition of the insurer. In addition, residents of Minnesota who purchase property and casualty or liability insurance from insurance companies authorized to do business in Minnesota are protected, SUBJECT TO LIMITS AND EXCLUSIONS, in the event the insurer becomes financially impaired or insolvent. This protection is provided by the Minnesota Insurance Guaranty Association. Minnesota Insurance Guaranty Association 4640 West 77th Street, Suite 342 Edina, Minnesota 55435 (612) 831-1908 The MAXIMUM AMOUNT the guaranty association will pay in regard to a claim under all policies issued by the same insurer IS LIMITED TO $300,000. This limit does not apply to worker's compensation insurance. Coverage by the guaranty association is subject to other substantial limitations and exclusions and requires continued residency in Minnesota. If your claim exceeds the Guaranty Associations' limits you may still recover a part or all of that amount from the proceeds from the liquidation of the insolvent insurer, if any exist. Funds to pay claims may not be immediately available. The Guaranty Association assesses insurers licensed to sell property and casualty insurance in Minnesota after the insolvency occurs. Claims are paid from the assessment. THE COVERAGE PROVIDED BY THE GUARANTY ASSOCIATION IS NOT A SUBSTITUTE FOR USING CARE IN SELECTING INSURANCE COMPANIES THAT ARE WELL MANAGED AND FINANCIALLY STABLE. IN SELECTING AN INSURANCE COMPANY OR POLICY, YOU SHOULD NOT RELY ON COVERAGE BY THE GUARANTY ASSOCIATION. THIS NOTICE IS REQUIRED BY MINNESOTA STATE LAW TO ADVISE POLICYHOLDERS OF PROPERTY AND CASUALTY INSURANCE POLICIES OF THEIR RIGHTS IN THE EVENT THEIR INSURANCE CARRIER BECOMES FINANCIALLY INSOLVENT. THIS NOTICE IN NO WAY IMPLIES THAT THE COMPANY CURRENTLY HAS ANY TYPE OF FINANCIAL PROBLEMS. ALL PROPERTY AND CASUALTY INSURANCE POLICIES ARE REQUIRED TO PROVIDE THIS NOTICE. I have read the foregoing notice and received a copy for my records this _________________ day of __________________________ '19___ _____________________________________________ POLICY HOLDER LWNMNIGA (ED. 11-91) INSURED'S COPY MISSOURI LIMIT OF LIABILITY ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by Part Two (Employers Liability Insurance) because Missouri is shown in Item 3.A. of the Information Page. We may not limit our liability to pay damages because of bodily injury by accident to your employees if the bodily injury arises out of and in the course of employment subject to, and is compensable under, the workers compensation law of Missouri, and the damages are claimed directly against you by the injured employee or, in the event of the death of the employee, by the persons entitled to sue therefor. _______________________________________________ WC 24 03 01 COUNTERSIGNED BY (ED. 4-84) AUTHORIZED REPRESENTATIVE INSURED'S COPY MISSOURI SAFETY CERTIFICATION ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by the policy because Missouri is shown in Item 3.A. of the Information Page. You may be eligible for a Missouri Safety Certification Premium Credit. You are eligible for this credit one time only. To be eligible you must provide us with verification of the safety certification and required number of reductions in injuries and illnesses and lost workdays. You may qualify for: 1. A five percent (5%) credit if in the first year the safety program has been in place you have reduced the number of injuries and illnesses and lost workdays, as calculated according to the Federal OSHA formula for incident rate, by at least fifty percent (50%). OR 2. A ten percent (10%) credit if in the first year the safety program has been in place you have experience no injuries and illnesses and lost workdays according to the Federal OSHA formula for incident rate. We will attach the Missouri Safety Certification Premium Adjustment Endorsement to the policy that is eligible for the premium credit. The Missouri Safety Certification Premium Adjustment Endorsement will indicate the amount of the credit for which you have provided verification as outlined above. ______________________________________________ WC 24 04 03 COUNTERSIGNED BY (ED. 06-93) AUTHORIZED REPRESENTATIVE INSURED'S COPY MISSOURI RETROSPECTIVE PREMIUM SUPPLEMENTAL ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement changes the Retrospective Premium Endorsement attached to the policy. The change applies only to the premium charged because Missouri is shown in Item 3.A. of the Information Page. 1. If the retrospective premium is determined by Rating Option I, II, III, or IV, incurred losses do not include interest on judgments or employers liability loss adjustment expenses. 2. If the retrospective premium is determined by Rating Option V, incurred losses do not include interest on judgments. ______________________________________________ WC 24 05 01 COUNTERSIGNED BY (ED. 04-84) AUTHORIZED REPRESENTATIVE INSURED'S COPY MISSOURI CANCELATION AND NONRENEWAL ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by the policy because Missouri is shown in Item 3.A. of the Information Page. The Cancelation Condition of the policy is replaced by these two Conditions: CANCELATION 1. You may cancel this policy. You will mail or deliver advance written notice to us, stating when the cancelation is to take effect. 2. We may cancel this policy. We will mail or deliver to you, by certified mail, not less than 30 days advance written notice stating when the cancelation is to take effect. Mailing this notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 3. The policy period will end on the day and hour stated in the cancelation notice. NONRENEWAL 1. We may elect not to renew the policy. We will mail to you not less than 30 days advance written notice stating when the nonrenewal will take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 2. If we fail to provide the notice of nonrenewal as required, the policy will still terminate on its expiration date if: a. we show you our willingness to renew the policy but you notify us or the agent or broker who procured this policy that you do not want the policy renewed; or b. you fail to pay all premiums when due; or c. you obtain other insurance as a replacement of the policy. _____________________________________________ WC 24 06 01 A COUNTERSIGNED BY (ED. 4-91) AUTHORIZED REPRESENTATIVE INSURED'S COPY MISSOURI PROPERTY AND CASUALTY GUARANTY ASSOCIATION ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by the policy because Missouri is shown in Item 3.A. of the Information Page. Missouri Property and Casualty Insurance Guaranty Association Coverage Limits: 1. Subject to the provisions of the Missouri Property and Casualty Insurance Guaranty Association Act (Act), if we are a member of the Missouri Property and Casualty Insurance Guaranty Association (Association), the Association will pay claims covered under the Act if we become insolvent. 2. The Act contains various exclusions, conditions and limitations that govern a claimant's eligibility to collect payment from the Association and affect the amount of any payment. The following limitations apply subject to all other provisions of the Act: a. Claims covered by the Association do not include a claim by or against an insured of an insolvent insurer if the insured has a net worth of more than $25 million on the date the insurer becomes insolvent. If the insured prepares an annual report to shareholders, or an annual report to management reflecting net worth, then such report for the fiscal year immediately preceding the date of insolvency of the insurer will be used to determine net worth. b. The Association will pay the full amount of any covered claim arising out of a workers compensation policy, but payments made by the Association for covered claims will include only that amount of each claim which is: (1) In excess of $100; and (2) Less than $300,000. However, the association will not: (1) Pay an amount in excess of the applicable limit of insurance of the policy from which a claim arises; or (2) Return to an insured any unearned premium in excess of $10,000. These limitations have no effect on the coverage we will provide under this policy. ______________________________________________ WC 24 06 02 A COUNTERSIGNED BY (ED. 04-96) AUTHORIZED REPRESENTATIVE INSURED'S COPY NOTICE TO THE POLICYHOLDER This notice is to inform you of the loss control programs available to you for servicing your Missouri locations. We have Field Safety Representatives with the experience and expertise to provide Comprehensive Safety Engineering and Management Services. Our services may include loss prevention surveys, risk exposure analysis, staff training, counseling, accident and loss analysis, worker health and safety evaluations, risk improvement recommendations, educational material and literature related to your specific profession or industry. If you have any questions or wish to discuss further the Loss Control Services available, contact: AIG Consultants, Inc. 500 W. Madison St., 9th Floor Chicago, IL 60661 Regional Manager - 1(312)930-6978 or call the Parsippany Loss Control Unit of AIG Consultants at 1(800)972-4420, 9 AM to 5 PM Eastern Standard Time. WC63612 (ED. 10-95) INSURED'S COPY NORTH CAROLINA AMENDED COVERAGE ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by the policy because North Carolina is shown in Item 3.A. of the Information Page. The CANCELATION Condition of the policy is replaced by this Condition: D. CANCELATION 1. You may cancel this policy. If you cancel this policy, you must mail or deliver not less than 10 days advance written notice to us stating when the cancelation is to take effect. 2. We may cancel this policy. a) If we cancel this policy for nonpayment of premium, we must mail or deliver not less than 10 days advance written notice to you stating when the cancelation is to take effect. b) If we cancel this policy for any reason other than nonpayment of premium, we must mail by registered or certified mail not less than 30 days advance written notice to you stating when the cancelation is to take effect. c) Mailing required notice of cancelation to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 3. The policy period will end on the day and hour stated in the cancelation notice. _____________________________________________ WC 32 03 01 A COUNTERSIGNED BY (ED. 10-93) AUTHORIZED REPRESENTATIVE INSURED'S COPY NEBRASKA CANCELATION ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA 1. You may cancel this policy within the policy period by giving notice in writing to the Nebraska Workers' Compensation Court and to us, fixing the date on which the cancelation is to be effective. 2. The notice, from you, is to be served personally or sent by certified mail. 3. The cancelation shall not be effective until 10 days after the mailing of the notice. 4. We may cancel this policy within the policy period by giving notice in writing to you and to the Nebraska Workers' Compensation Court, fixing the date on which the cancelation is to be effective. 5. The notice, from us, is to be served personally or sent by certified mail. 6. The cancelation shall not be effective until 10 days after the mailing of the notice unless you have secured insurance with another insurer. In this event the cancelation will be effective as of the effective date of the other insurance. 7. We are required by Nebraska Law to give notice of your intent to cancel a policy to the Nebraska Workers' Compensation Court. ______________________________________________ WC 26 06 01 A COUNTERSIGNED BY (ED. 7-92) AUTHORIZED REPRESENTATIVE INSURED'S COPY NEW HAMPSHIRE SOLE REPRESENTATIVE ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by the policy because New Hampshire is shown in Item 3.A. of the Information Page. Condition E, "Sole Representative", of the policy is replaced by the following: "The insured first named in Item 1 of the Information Page will act on behalf of all insureds to change this policy, receive return premium or to give us notice of cancellation. If we cancel this policy, we will give each named insured notice of cancellation". ______________________________________________ WC 28 06 01 COUNTERSIGNED BY (ED. 4-84) AUTHORIZED REPRESENTATIVE INSURED'S COPY NEW HAMPSHIRE AMENDATORY ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the New Hampshire coverage provided by the policy as New Hampshire is shown in Item 3.A. of the Information Page. For New Hampshire coverage, the cancelation condition of the policy is amended and replaced by: 1. You may cancel this policy. You must mail or deliver advance written notice to us. 2. We may cancel this policy. We will file a written termination notice with the commissioner of the Department of Labor and will send a copy to you. 3. In case of non payment of premium, the cancelation will take effect 30 days after the termination notice is filed. 4. In case of cancelation for reasons other than non payment of premium, cancelation will take effect 45 days after the notice of termination is filed. 5. If you have obtained coverage from another insurance carrier or have qualified as a self-insurer, cancelation is effective on the date you obtained the coverage or qualified as a self-insurer. ______________________________________________ WC 28 06 04 COUNTERSIGNED BY (ED.4-92) AUTHORIZED REPRESENTATIVE INSURED'S COPY NEW JERSEY PART TWO LIMIT OF LIABILITY ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by Part Two (Employers Liability Insurance) because New Jersey is shown in Item 3.A. of the Information Page. We may not limit our liability to pay damages for which we become legally liable to pay because of bodily injury to your employees if the bodily injury arises out of and in the course of employment that is subject to, and is compensable under, the workers compensation law of New Jersey. ______________________________________________ WC 29 03 01 COUNTERSIGNED BY (ED. 4-84) AUTHORIZED REPRESENTATIVE INSURED'S COPY ENDORSEMENT This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-40 Issued to: OUTSOURCE INTERNATIONAL, INC. BY: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA NEW JERSEY SECOND INJURY FUND The New Jersey Workers Compensation Law established the Second Injury Fund to provide benefits to workers who become permanently and totally disabled as a result of work-related injury or occupational disease when the worker had been previously partially disabled. The Law also requires that the Fund provide annual adjustments to certain persons permanently and totally disabled and to certain dependents of deceased workers. Through 1988, the Second Injury Fund was financed by an annual assessment upon insurance carriers. Such assessment was included in your standard premium via the manual premium rate(s) shown in your policy Information Page. Effective January 1, 1989 an amendment to the Law requires that the present financing be replaced by a direct surcharge shown as a separate "Second Injury Fund Surcharge" line on the policy Information Page. It will no longer be included in the manual premium rate. This new system will discourage other states from imposing retaliatory taxes on New Jersey based insurance companies and ultimately aid cost containment efforts. Issue Date: 04/10/97 ______________________________________________ LWNNJSIF COUNTERSIGNED BY AUTHORIZED REPRESENTATIVE INSURED'S COPY ENDORSEMENT This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-40 Issued to: OUTSOURCE INTERNATIONAL, INC. BY: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA The New Jersey Workers Compensation Law requires every employer to provide workers compensation coverage through purchase of a workers compensation and employers liability insurance policy. Failure to provide such coverage results in a fine and/or criminal action by the Department of Labor as well as continued liability for benefit payments to an injured worker. The Uninsured Employers Fund was established by Law to provide benefits to an injured worker when the employer has failed to comply with the insurance provision of the Law and is unable to provide the required benefits. Through 1988, total financing of the Fund was derived from fines imposed upon uninsured employers. Effective January 1, 1989 an amendment to the Law, requires that the present financing be supplemented by a direct surcharge shown as a separate "Uninsured employers Fund Surcharge" line on your policy Information Page. This method will assure the delivery of benefits to injured workers and the surcharge will cease whenever the year end balance of the Fund exceeds $500,000. _______________________________________________ AUTHORIZED REPRESENTATIVE Issue Date: 04/10/97 INSURED'S COPY NEW MEXICO SAFETY DEVICE EXCLUSION ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA Section 52-1-10 of the New Mexico workers compensation law may make you liable for the payment of additional benefits in the case of bodily injury to employees resulting from your failure to supply safety devices. The policy does not cover these additional benefits. ______________________________________________ WC 30 03 02 COUNTERSIGNED BY (ED. 4-84) AUTHORIZED REPRESENTATIVE INSURED'S COPY NEW MEXICO CANCELATION AND NONRENEWAL ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies to the insurance provided by the policy because New Mexico is shown in Item 3.A. of the Information Page. The Cancelation Condition of this policy is replaced by the following: CANCELATION You may cancel this policy by returning it to us or by giving us a written notice and stating at what future time coverage is to cease. We may cancel this policy, or one or more of its parts, by giving you a written notice. If the premium has not been paid when due, we may cancel at any time by giving the required notice at least 10 days before the cancelation is effective. If the policy has been in effect less than 60 days and is not a renewal policy, we may cancel by giving the required notice at least 10 days before the cancelation is effective. If the policy has been in effect for 60 days or more or is a renewal, we may cancel only for one or more of the following reasons: a. The policy was obtained through material misrepresentation, fradulent statements, omissions or concealment of fact material to the acceptance of the risk or to the hazard assumed by us; b. Willful and negligent acts or omissions by the insured have substantially increased the hazards insured against; c. You presented a claim based on fraud or material misrepresentation; or d. There has been a substantial change in the risk assumed by us since the policy was issued. We will give the required Notice of Cancelation stating the reason(s) for cancelation at least 30 days before the cancelation is effective. The notice will state the time that the cancelation is to take effect. The notice will be sent to your mailing address last known to us. Your return premium, if any, will be calculated as follows: a. If we cancel, we will return all unearned premiums. b. If you cancel, the refund will be calculated according to our rules. Your return premium will be refunded to you with the cancelation notice or within a reasonable time. Payment or tender of the unearned premium is not a condition of cancelation. NONRENEWAL If we decide not to renew this policy, we must give you written notice of our intention not less than 30 days prior to the expiration of the policy. This nonrenewal section does not apply to any policy of insurance issued to an insured who has its principal place of business outside this state. _____________________________________________ WC 30 06 01 COUNTERSIGNED BY (ED. 1-90) AUTHORIZED REPRESENTATIVE INSURED'S COPY NEW YORK LIMIT OF LIABILITY ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by Part Two (Employers Liability Insurance) because New York is shown in item 3.A. of the Information Page. We may not limit our liability to pay damages for which we become legally liable to PAY because of bodily injury to your employees if the bodily injury arises out of and in the course of employment that is subject to and is compensable under the Workers Compensation Law of New York. _____________________________________________ WC 31 03 08 COUNTERSIGNED BY (ED. 4-84) AUTHORIZED REPRESENTATIVE INSURED'S COPY NOTICE TO POLICYHOLDERS NEW YORK CHANGES TO ASSESSMENTS Legislation enacted in December 1993 and applicable to policies effective April 1st, 1994 specifically prohibited assessments based on losses. The New York Compensation Rating Board was instructed to prepare a single "New York State Assessment" to be charged based on your standard workers compensation premium, which is your premium after application of experience modification. For your information, the components of this assessment are described below. These assessment percentages are effective on new and renewal policies effective October 1, 1994 and later. WORKERS COMPENSATION BOARD (WCB) ASSESSMENT The WCB is the administrator of the workers compensation law in New York. Its administrative law judges hear cases and establish benefit eligibility and awards. The assessment for this service is 2.56% REOPENED CASE FUND The Reopened Case Fund pays for benefits determined by the Workers Compensation Board after a lapse of seven years from the date of injury, or in those cases where an earlier determination is set aside. The assessment for this service is 4.76% SPECIAL DISABILITY FUND The Special Disability Fund provides for the reimbursement of the insurance company for compensation and medical benefits paid as the result of a subsequent (second) injury. The assessment for this service is 6.06% INTERDEPARTMENTAL EXPENSES This assessment pays for the programs administered by the New York Department of Health, Occupational Health Clinics Network, and the New York Department of Labor, both the Occupational Safety and Training Fund and the Enforcement of Occupational Safety and Health Regulation. The assessment for these services is 0.54% SPECIAL FUNDS CONSERVATION COMMITTEE This assessment pays the expenses of the state attorney responsible for handling second injury and reopened case matters. The assessment for this service is 0.18% The total assessment effective October 1, 1995 is 14.1%. WC62942 (ED.10-95) INSURED'S COPY PENNSYLVANIA NOTICE TO POLICYHOLDERS Pennsylvania law requires that we provide our policyholders with certain accident prevention services. For your consideration, we have the services of AIG Consultants, Inc., a professional engineering company with established experience and expertise. AIG Consultants, Inc. can address a significant range of commercial problems and advise and assist you in recognizing and solving existing and potential problems for accidents and occupational health hazards. AIG Consultants, Inc. has been operating for more than 15 years and when utilized has responded to individual client's problem to provide efficient consultative services by qualified safety consultants. These safety and health consultative services consist of, but are not limited to, the following: 1. A survey of the safety performance of the risk and its activates. 2. An appraisal of the mechanical hazards, materials handling, unsafe work methods and hazardous process. 3. Advice and assistance in the detection of occupational health hazards and exposures. 4. Assistance to the risk with employee safety and health training programs. 5. Recommendations for appropriate corrective action as result of any survey. 6. Assistance in the development of a safety and health program. Address all inquires to the following: AIG Consultants, Inc. 2005 Market Street, Suite 2900 Philadelphia, PA 19103 Telephone:(215) 981-7351 ______________________________________________ 59472 WC COUNTERSIGNED BY (ED. 01-94) AUTHORIZED REPRESENTATIVE INSURED'S COPY SPECIAL PENNSYLVANIA ENDORSEMENT-INSPECTION OF MANUALS This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA The manuals of rules, rating plans, and classifications are approved pursuant to the provisions of Section 654 of the Insurance Company Law of May 17, 1921, P.L. 682, as amended, and are on file with the Insurance Commissioner of the Commonwealth of Pennsylvania. ______________________________________________ WC 37 06 01 COUNTERSIGNED BY (ED. 4-84) AUTHORIZED REPRESENTATIVE INSURED'S COPY PENNSYLVANIA NOTICE This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA An Insurance Company, its agents, employees, or service contractors acting on its behalf, may provide services to reduce the likelihood of injury, death or loss. These services may include any of the following or related services incident to the application for, issuance, renewal or continuation of, a policy of insurance: 1. surveys; 2. consultation or advice; or 3. inspections. The "Insurance Consultation Services Exemption Act" of Pennsylvania provides that the Insurance Company, its agents, employees or service contractors acting on its behalf, is not liable for damages from injury, death or loss occurring as a result of any act or omission by any person in the furnishing of or the failure to furnish these services. The Act does not apply: 1. if the injury, death or loss occurred during the actual performance of the services and was caused by the negligence of the Insurance Company, its agents, employees or service contractors; 2. to consultation services required to be performed under a written service contract not related to a policy of insurance; or; 3. if any acts or omissions of the Insurance Company, its agents, employees or service contractors are judicially determined to constitute a crime, actual malice, or gross negligence. ______________________________________________ WC 37 06 02 COUNTERSIGNED BY ED. 4-84) AUTHORIZED REPRESENTATIVE INSURED'S COPY PENNSYLVANIA ACT 86-1986 ENDORSEMENT NONRENEWAL,NOTICE OF INCREASE OF PREMIUM, and RETURN OF UNEARNED PREMIUM This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by the policy because Pennsylvania is shown in Item 3.A. of the Information Page. The policy conditions are amended by adding the following regarding nonrenewal, notice of increase in premium, and return of unearned premium. NONRENEWAL 1. We may elect not to renew the policy. We will mail each named insured, by first class mail, not less than 60 days advance notice stating when the nonrenewal will take effect. Mailing that notice to you at your mailing address last known to us will be sufficient to prove notice. 2. Our notice of nonrenewal will state our specific reasons for not renewing. 3. If we have indicated our willingness to renew, we will not send you a notice of nonrenewal. However, the policy will still terminate on its expiration date if: a. you notify us or the agent or broker who procured this policy that you do not want the policy renewed; or b. you fail to pay all premiums when due; or c. you obtain other insurance as a replacement of the policy. NOTICE OF INCREASE IN PREMIUM 1. We will provide you with not less than 60 days of intent to increase the premium on the renewal of this policy, if it is our intent to offer such renewal. 2. We will provide you with not less than 30 days notice of an estimate of the renewal premium, if it is our intent to offer such renewal. 3. The above notification requirements will be satisfied if we have issued a renewal policy before the time periods indicated in Items 1. and 2. above. 4. If a policy has been written or is to be written on a retrospective rating plan basis, the notice of increase in premium provisions of this endorsement do not apply. WC 37 06 03 (ED. 12-87) 1 OF 2 INSURED'S COPY RETURN OF UNEARNED PREMIUM 1. If this policy is canceled and there is unearned premium due you: a. If the company cancels, the unearned premium will be returned to you within 10 business days after the effective date of cancelation. b. If you cancel, the unearned premium will be returned within 30 days after the effective date of cancelation. 2. Because this policy was written on the basis of an estimated premium and is subject to a premium audit, the unearned premium specified in la. and lb. above, if any, shall be returned on an estimated basis. Upon our completion of computation of the exact premium, an additional return premium or charge will be made to you within 15 days of the final computation. 3. These return or unearned premium provisions shall not apply if this policy is written on a retrospective rating plan basis. _______________________________________________ WC 37 06 03 COUNTERSIGNED BY (ED. 12-87) AUTHORIZED REPRESENTATIVE 2 OF 2 INSURED'S COPY SOUTH DAKOTA DIRECT ACTION STATUTE ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by Part Two (Employers Liability Insurance) because South Dakota is shown in item 3.A of the Information Page. 1. Your injured employee, or the persons entitled to sue you for damages in the event of the death of the employee, may add us as a defendant in a suit against you to recover damages because of bodily injury or death to your employee. 2. We are directly liable to pay to your injured employee, or to the persons entitled to sue you for damages in the event of the death of your employee, the damages for which you are liable. This endorsement is subject to all provisions of Part Two (Employers Liability Insurance) that do not conflict with the direct action statute (Section 58.20.12) of the South Dakota workers compensation law. _____________________________________________ WC 40 06 01 COUNTERSIGNED BY (ED.4-84) AUTHORIZED REPRESENTATIVE INSURED'S COPY SOUTH DAKOTA NOTICE TO THE INSURED DEAR WORKER'S COMPENSATION POLICYHOLDER: Pursuant to SENATE BILL 310, the State of South Dakota requires that we inform you of our available South Dakota safety review services for Workers Compensation. For your consideration, we have the services of AIG Consultants, Inc., a professional engineering company with established experience and expertise. AIG Consultants, Inc. can address a significant range of commercial problems and advise and assist you in recognizing and solving existing and potential problems for accidents and occupational health hazards. AIG Consultants, Inc. has been operating for more than 15 years and when utilized, has responded to individual client's problems to provide efficient consultative services by qualified safety consultants. These safety and health consultative services consist of, but are not limited to, the following: 1) A survey of the safety performance of the risk and its activities. 2) An appraisal of the mechanical hazards, materials handling, unsafe work methods, and hazardous processes. 3) Advice and assistance in the direction of occupational health hazards and exposures. 4) Assistance to the risk with employee safety and health training programs. 5) Recommendations for appropriate corrective action as a result of any survey. 6) Assistance in the development of a safety and health program. If your Workers Compensation premium is $5,000 or greater, you are required to have a safety review at least once every three (3) years. If as a result of a safety review, written recommendations identify a safety deficiency must be corrected, and it has not been corrected at the time of a subsequent review, you will be subject to an appropriate increase in premium. If you would like more information on our safety review services, contact our office at: AIG Consultants Inc. 500 West Madison, 9th Fl. Chicago, IL 60661-2511 Phone: (312) 930-5528 Fax: (312) 930-5607 WC 58978 (ED. 10-93) INSURED'S COPY TEXAS AMENDATORY ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by the policy because Texas is shown in item 3.A of the Information Page. GENERAL SECTION B. WHO IS INSURED is amended to read: You are insured if you are an employer named in item 1 of the Information Page. If that employer is a partnership or joint venture, and if you are one of its partners or members, you are insured, but only in your capacity as an employer of the partnership's or joint venture's employees. D. STATE is amended to read: State means any state or territory of the United States of America, and the District of Columbia. PART ONE - WORKERS COMPENSATION INSURANCE E. OTHER INSURANCE is amended by adding this sentence: This section only applies if you have other insurance or are self-insured for the same loss. F. PAYMENTS YOU MUST MAKE This section is amended by deleting the words "workers compensation" from number 4. H. STATUTORY PROVISIONS This section is amended by deleting the words "after an injury occurs" from number 2. PART TWO - EMPLOYERS LIABILITY INSURANCE C. EXCLUSIONS Section 2 and 3 are amended to add: This exclusion does not apply unless the violation of law caused or contributed to the bodily injury. Section 6 is amended to read: 6. bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America, Mexico or Canada who is temporarily outside these countries. D. WE WILL DEFEND This section is amended by deleting the last sentence. PART FOUR - YOUR DUTIES IF INJURY OCCURS Number 6 of this part is amended to read: 6. Texas law allows you to make weekly payments to an injured employee in certain instances. Unless authorized by law, do not voluntarily make payments, assume obligations or incur expenses, except at your own cost. WC 42 03 01D (ED. 1-96) Page 1 of 3 INSURED'S COPY PART FIVE - PREMIUM A. OUR MANUALS is amended by adding the sentence: In this part, "our manuals" means manuals approved or prescribed by the State Board of Insurance. C. REMUNERATION Number 2 is amended to read: 2. All other persons engaged in work that would make us liable under Part One (Workers Compensation Insurance) of this policy. This paragraph 2 will not apply if you give us proof that the employers of these persons lawfully secured workers compensation insurance. PART SIX - CONDITIONS A. INSPECTION is amended by adding this sentence: Your failure to comply with the safety recommendations made as a result of an inspection may cause the policy to be canceled by us. C. TRANSFER OF YOUR RIGHTS AND DUTIES is amended to read: Your rights and duties under this policy may not be transferred without our written consent. If you die, coverage will be provided for your surviving spouse or your legal representative. This applies only with respect to their acting in the capacity as an employer and only for the workplaces listed in items 1 and 4 on the Information Page. D. CANCELATION is amended to read: 1. You may cancel this policy. You must mail or deliver advance notice to us stating when the cancelation is to take effect. 2. We may cancel this policy. We may also decline to renew it. We must give you written notice of cancelation or nonrenewal. That notice will be sent certified mail or delivered to you in person. A copy of the written notice will be sent to the Texas Workers Compensation Commission. 3. Notice of cancelation or nonrenewal must be sent to you not later than the 30th day before the date on which the cancelation or nonrenewal becomes effective, except that we may send the notice not later than the 10th day before the date on which the cancelation or nonrenewal becomes effective if we cancel or do not renew because of: a. Fraud in obtaining coverage; b. Failure to pay a premium when payment was due; c. An increase in the hazard that results from an action or omission and that would produce an increase in the rate, including an increase because of failure to comply with reasonable recommendations for loss control or to comply within a reasonable period with recommendations designed to reduce a hazard that is under your control; d. A determination by Commissioner of Insurance that the continuation of the policy would place us in violation of the law, or would be hazardous to the interests of subscribers, creditors, or the general public. 4. If another insurance company notifies the Texas Workers Compensation Commission that it is insuring you as an employer, such notice shall be a cancelation of this policy effective when the other policy starts. PART SEVEN - OUR DUTY TO YOU FOR CLAIM NOTIFICATION A. CLAIMS NOTIFICATION We are required to notify you of any claim that is filed against your policy. Thereafter we shall notify you of any proposal to settle a claim or, on receipt of a written request from you, of any administrative or judicial proceeding relating to the resolution of a claim, including a benefit review conference conducted by the Texas Workers' Compensation Commission. You may, in writing, elect to waive this notification requirement. WC 42 03 OID (ED. 1-96) Page 2 of 3 INSURED'S CODY We shall, on written request from you, provide you with a list of claims charged against your policy, payments made and reserves established on each claim, and a statement explaining the effect of claims on your premium rates. We must furnish the requested information to you no later than the 30th day after the date we receive your request. The information is considered to be provided on the date the information is received by the United States Postal Service or is personally delivered. COMPLAINT NOTICE: SHOULD ANY DISPUTE ARISE ABOUT YOUR PREMIUM OR ABOUT A CLAIM THAT YOU HAVE FILED, CONTACT THE AGENT OR WRITE TO THE COMPANY THAT ISSUED THE POLICY. IF THE PROBLEM IS NOT RESOLVED, YOU MAY ALSO WRITE THE STATE BOARD OF INSURANCE, P.O. BOX 149091, AUSTIN, TEXAS 78714-9091, FAX# (512)475-1771. THIS NOTICE OF COMPLAINT PROCEDURE IS FOR INFORMATION ONLY AND DOES NOT BECOME A PART OR CONDITION OF THIS POLICY. ________________________________________________ WC 42 03 OID COUNTERSIGNED BY (ED 1-96) AUTHORIZED REPRESENTATIVE Page 3 of 3 INSURED'S COPY TEXAS MAINTENANCE TAX SURCHARGE RECOUPMENT ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA A. This endorsement is added pursuant to the Insurance Code, Article 5.76-5, Section 10(d) and hereby amends the policy to impose an additional charge to the standard policy premium after premium discount in the amount sufficient to allow the insurance company to recoup the maintenance tax surcharges as provided for by 28 TAC (section) 1.411. B. Maintenance tax surcharges are imposed against each insurance company writing workers' compensation insurance to pay debt service for $300 million in bonds issued on behalf of the Texas Workers' Compensation Insurance Fund by the Texas Public Finance Authority. C. The insurance company, at its option, has elected to pass this surcharge amount on to the policyholder. This endorsement changes the policy to which it is attached and is effective on the policy effective date unless otherwise stated. Schedule Percentage of Premium for Recoupment .5900 %. ______________________________________________ WC 42 03 06 COUNTERSIGNED BY (ED. 7-92) AUTHORIZED REPRESENTATIVE INSURED'S COPY TEXAS EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 0 1 /01/97 RM WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA The premium for the policy will be adjusted by an experience rating modification factor, if any, which was not available when the policy was issued. We will issue an endorsement to show the proper factor when it is calculated. ______________________________________________ WC 42 04 03 COUNTERSIGNED BY (ED. 4-84) AUTHORIZED REPRESENTATIVE INSURED'S COPY DEDUCTIBLE NOTICE OF ELECTION TO ACCEPT TEXAS WORKERS' COMPENSATION BENEFITS This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 WC 217-79-40 Issued to OUTSOURCE INTERNATIONAL, INC By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA Texas law permits an employer to obtain Workers' Compensation insurance with a deductible. The deductible applies to benefits payable under Texas Workers' Compensation Law. The insurance applies only to benefits in excess of the deductible amount. The deductible applies separately to each accident or disease regardless of the number of people who sustain injury by such accident or disease or as an annual aggregate or as a combination of both. The deductible plans have been explained to me. Premium reductions are determined based on the deductible selected and the hazard group. The hazard group is determined by the classification that produces the largest amount of estimated Texas standard premium. You are not required to choose a deductible. If you do choose one, your insurance company will pay the deductible amount for you, but you must reimburse the insurance company within 30 days after they send you notice that payment is due. If you fail to reimburse the insurance company, they may cancel the policy, upon ten days written notice, and any resulting premium may be applied to the deductible amount owed. If a deductible amount is desired, please indicate below. [ ] Yes, I want a deductible of: (select only one) 1. $ per accident 2. $ annual aggregate 3. $ /$ per accident/annual aggregate applied to benefits payable under the Texas Workers' Compensation Law. I understand that the company will pay the deductible amount and seek reimbursement ------------------------------ (monthly, quarterly or other) [ ] No, I do not want a deductible applied to benefits payable under the Texas Workers' Compensation Law. [ ] Yes, I do want a deductible policy, but I'm unable to obtain for the following reason: - ------------------------------------- ----------------------------- Employer Name (Print or type) Date - ------------------------------------- ----------------------------- Signature & Title Policy Number _______________________________________________ LWNTXDED COUNTERSIGNED BY (ED. 1-92) AUTHORIZED REPRESENTATIVE INSURED'S COPY PAGE 001 ENDORSEMENT # 00001 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-40 Issued to: OUTSOURCE INTERNATIONAL, INC. By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA NAMED INSUREDS FEIN -------------- ---- 00001 OUTSOURCE INTERNATIONAL, INC. 592754571 00002 SYNADYNE I 650021598 (DBA) PAYROLL PARNERS 00003 LABOR WORLD OF AMERICA, INC. 592754571 (DBA) SYNADYNE III 00004 OUTSOURCE FRANCHISING, INC. 592754571 00005 SYNADYNE II 650021598 (DBA) PAYROLL PARTNERS 00006 SYNADYNE IV 650021598 00007 SYNADYNE V 650021598 00008 CAPITAL STAFFING FUND, INC. 592754571 00009 SMSB ASSOCIATES, INC. 592754571 ---------------------------------- Authorized Representative Issue Date: 04/10/97 lw0003 INSURED'S COPY PAGE 001 ENDORSEMENT # 00002 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-40 Issued to: OUTSOURCE INTERNATIONAL, INC. By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA ADDITIONAL LOCATIONS -------------------- 00001 8000 NORTH FEDERAL HIGHWAY BOCA RATON FL 33487 00002 101 AIRPORT ROAD HARTFORD CT 06114 00003 4601 NORTHWEST 17TH WAY FT. LAUDERDALE FL 33309 00004 6935 GRAND AVENUE HAMMOND IN 46323 00005 301 NORTH ALMONESSON RD. DEPTFORD NJ 08096 00006 10500 ROOSEVELT BLVD. PHILADELPHIA PA 19116 00007 449 S. ADDISON RD. ADDISON IL 60101 00008 3313 ROSCHESTER RD. ROYAL OAK MI 48073 00009 720 EAST JOHNSON HWY. NORRISTOWN PA 19401 00010 JOBSITE ONLY ANCHORAGE AK 99501 ------------------------------------ Authorized Representative Issue Date: 04/10/97 lwO004 INSURED'S COPY PAGE 002 ENDORSEMENT # 00002 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-40 Issued to: OUTSOURCE INTERNATIONAL, INC. By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA ADDITIONAL LOCATIONS -------------------- 00011 JOBSITE ONLY BIRMINGHAM AL 35201 00012 100 CORPORATE N., STE 300 BANNOCK BURN IL 60015 00013 JOBSITE ONLY FREEMONT IN 46737 00014 JOBSITE ONLY FORT KNOX KY 40121 00015 2050 #100 CANAL ST NEW ORLEANS LA 70112 00016 JOBSITE ONLY DETROIT MI 48073 00017 JOBSITE ONLY PRINCETON MN 55371 00018 6310 1-55 NORTH, STE 400 JACKSON MS 39211 00019 8801 J.M. KEYNES DR., STE 300 CHARLOTTE NC 28213 00020 JOBSITE ONLY ABUELO NM 87732 ----------------------------------- Authorized Representative Issue Date: 04/10/97 lwO004 INSURED'S COPY PAGE 003 ENDORSEMENT # 00002 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-40 Issued to: OUTSOURCE INTERNATIONAL, INC. By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA ADDITIONAL LOCATIONS -------------------- 00021 JOBSITE ONLY PHILADELPHIA PA 19148 00022 JOBSITE ONLY ABBEVILLE SC 29620 00023 151 LAFAYETTE STREET NASHVILLE TN 37210 00024 13357 SOUTH OLDE WESTERN AVE. BLUE ISLAND IL 60406 00025 3348 N. PULASKI CHICAGO IL 60641 00026 1547 NORTHWESTERN AVE. CHICAGO IL 60622 00027 3452 SOUTH WESTERN AVE. CHICAGO IL 60608 00028 6606 BARRINGTON RD. HANOVER PARK IL 60103 00029 1772 WEST ALGONQUIN RD. MT. PROSPECT IL 60056 00030 810 LAKE STREET MUNDELEIN IL 60060 ----------------------------------- Authorized Representative Issue Date: 04/10/97 lwO004 INSURED'S COPY PAGE 004 ENDORSEMENT # 00002 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-40 Issued to: OUTSOURCE INTERNATIONAL, INC. By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA ADDITIONAL LOCATIONS -------------------- 00031 6248 S. ARCHER SUMMIT IL 60501 00032 728 BELVIDERE RD. WAUKEGAN IL 60085 00033 44 E. NORTH AVE. NORTHLAKE IL 60164 00034 27 SNYDER AVENUE PHILADELPHIA PA 19148 00035 JOBSITE ONLY WASHINGTON DC 20315 00036 JOBSITE ONLY PITTSBURGH PA 15201 00037 JOBSITE ONLY CHICAGO IL 60606 00038 JOBSITE ONLY NEW ORLEANS LA 70101 00039 JOBSITE ONLY MINNEAPOLIS MN 55401 00040 JOBSITE ONLY KNOXVILLE TN 37901 ------------------------------------- Authorized Representative Issue Date: 04/10/97 lwO004 INSURED'S COPY PAGE 005 ENDORSEMENT # 00002 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-40 Issued to: OUTSOURCE INTERNATIONAL, INC. By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA ADDITIONAL LOCATIONS -------------------- 00041 JOBSITE ONLY NASHVILLE TN 37201 00042 3100 DUNDEE ROAD, STE 301 NORTHBROOK IL 60062 00043 916 FRANSWORTH AURORA IL 60505 00044 101 AIRPORT ROAD HARTFORD CT 06114 00045 JOBSITE ONLY WASHINGTON DC 20315 00046 6301 N.W. 5TH WAY FT. LAUDERDALE FL 33309 00047 950 GLADES ROAD, STE 3 BOCA RATON FL 33431 00048 42 N.W. 27TH AVE., STE 400 MIAMI FL 33125 00049 1451 N.W. 62ND ST., STE 212 FT. LAUDERDALE FL 33309 00050 400 N.W. 2ND AVENUE BOCA RATON FL 33432 ------------------------------------- Authorized Representative Issue Date: 04/10/97 lwO004 INSURED'S COPY PAGE 006 ENDORSEMENT # 00002 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-40 Issued to: OUTSOURCE INTERNATIONAL, INC. By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA ADDITIONAL LOCATIONS -------------------- 00051 1701 A COSTA DEL SOL BOCA RATON FL 33432 00052 615 N.E. 3RD AVE. FT. LAUDERDALE FL 33304 00053 6405 N. FEDERAL HWY, STE 200 FT. LAUDERDALE FL 33308 00054 3696 N. FEDERAL HWY, STE 101 FT. LAUDERDALE FL 33308 00055 700 E. OAKLAND PARK BLVD. FT. LAUDERDALE FL 33334 00056 7967 N.W. 21ST STREET MIAMI FL 33122 00057 902 CLINT MOORE RD., STE 132 BOCA RATON FL 33487 00058 3020 NW 33RD AVENUE FT. LAUDERDALE FL 33311 00059 1261 NW 116TH AVENUE PLANTATION FL 33323 00060 6605 NW 74TH AVENUE MIAMI FL 33166 ------------------------------------ Authorized Representative Issue Date: 04/10/97 lwO004 INSURED'S COPY PAGE 007 ENDORSEMENT # 00002 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-40 Issued to: OUTSOURCE INTERNATIONAL, INC. By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA ADDITIONAL LOCATIONS -------------------- 00061 490l NW 17TH WAY, STE 402 FT. LAUDERDALE FL 33309 00062 5411 WEST TYSON AVE TAMPA FL 33611 00063 300 FIRST AVE. SOUTH ST. PETERSBURG FL 33701 00064 2328 1OTH AVE. NORTH, STE 2-C LAKE WORTH FL 33461 00065 160l N. PALM AVENUE PEMBROKE PINES FL 33026 00066 111 2ND AVENUE NE ST. PETERSBURG FL 33701 00067 4037 66TH STREET NORTH ST. PETERSBURG FL 33709 00068 3696 NORTH FEDERAL HWY FT. LAUDERDALE FL 33308 00069 819 NE 26TH STREET FT. LAUDERDALE FL 33305 00070 1052 NW 3RD STREET HALLANDALE FL 33009 ------------------------------------ Authorized Representative Issue Date: 04/10/97 lwO004 INSURED'S COPY PAGE 008 ENDORSEMENT # 00002 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-40 Issued to: OUTSOURCE INTERNATIONAL, INC. By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA ADDITIONAL LOCATIONS -------------------- 00071 2635 N. STATE ROAD 7 FT. LAUDERDALE FL 33313 00072 5411 N. TYSON AVENUE TAMPA FL 33611 00073 6301 NW 5TH WAY, STE 4100 FT. LAUDERDALE FL 33309 00074 2232 CENTRAL AVENUE ST. PETERSBURG FL 33712 00075 4037 66TH STREET N ST. PETERSBURG FL 33709 00076 6935 GRAND AVENUE HAMMOND IN 46323 00077 JOBSITE ONLY NEW ORLEANS LA 70101 00078 301 NORTH ALMONESSON RD. DEPTFORD NJ 08096 00079 6049 A NEW PEACHTREE RD. DORAVILLE GA 30345 00080 7000 CENTRAL PKWY, STE 700 ATLANTA GA 30328 ------------------------------------ Authorized Representative Issue Date: 04/10/97 lwO004 INSURED'S COPY PAGE 009 ENDORSEMENT # 00002 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-40 Issued to: OUTSOURCE INTERNATIONAL, INC. By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA ADDITIONAL LOCATIONS -------------------- 00081 1030 WINDY HILL ROAD, S.E. SMYRNA GA 30080 00082 3460 MAIN ST. HARTFORD CT 06120 00083 BOX E, LAKE ST. MINNEAPOLIS MN 55407 00084 113 1/2 MAIN ST. CRYSTAL LAKE IL 60014 00085 308 DUNDEE AVE ELGIN IL 60120 00086 318 REPUBLIC AVE JOLIET IL 60435 00087 1110 GALLATION RD. NASHVILLE TN 37206 00088 425 15TH AVE. ROCKFORD IL 61104 00089 NEED ADDRESS ENTIRE STATE AR 99999 00090 NEED ADDRESS ENTIRE STATE IA 99999 ------------------------------------ Authorized Representative Issue Date: 04/10/97 lwO004 INSURED'S COPY PAGE 010 ENDORSEMENT # 00002 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-40 Issued to: OUTSOURCE INTERNATIONAL, INC. By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA ADDITIONAL LOCATIONS -------------------- 00091 NEED ADDRESS ENTIRE STATE MA 99999 00092 NEED ADDRESS ENTIRE STATE MO 99999 00093 NEED ADDRESS ENTIRE STATE NE 99999 00094 NEED ADDRESS ENTIRE STATE NH 99999 00095 NEED ADDRESS ENTIRE STATE NY 99999 00096 NEED ADDRESS ENTIRE STATE SD 99999 00097 NEED ADDRESS ENTIRE STATE TX 99999 ------------------------------------ Authorized Representative Issue Date: 04/10/97 lwO004 INSURED'S COPY ENDORSEMENT # 00004 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-40 Issued to: OUTSOURCE INTERNATIONAL, INC. By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA STATE NAMED INSURED STATE/UNEMPLOYMENT ID - ----- ------------- --------------------- MN OUTSOURCE INTERNATIONAL, INC. 1249457 MN SYNADYNE I 1249457 MN LABOR WORLD OF AMERICA, INC. 1249457 ------------------------------------- Authorized Representative ISSUE DATE: 04/10/97 lwO007 INSURED'S COPY ENDORSEMENT # 00003 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-40 Issued to: OUTSOURCE INTERNATIONAL, INC. BY: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA NOTICE OF CANCELLATION PART SIX, PARAGRAPH D.2. OF THE WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY IS REPLACED BY THE FOLLOWING: WE MAY CANCEL THIS POLICY. WE MUST MAIL OR DELIVER TO YOU NOT LESS THAN NINETY (90) DAYS ADVANCE WRITTEN NOTICE, TEN (10) DAYS FOR NONPAYMENT OF PREMIUM STATING WHEN THE CANCELLATION IS TO TAKE EFFECT. MAILING THAT NOTICE TO YOU AT YOUR MAILING ADDRESS SHOWN IN ITEM 1 OF THE INFORMATION PAGE WILL BE SUFFICIENT TO PROVE NOTICE. ---------------------------------- Authorized Representative Issue Date: 04/10/97 lwO014 INSURED'S COPY ENDORSEMENT This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-40 Issued to: OUTSOURCE INTERNATIONAL, INC. By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA THIS POLICY PROVIDES NO COVERAGE IN THE STATE OF MAINE. ----------------------------------- Authorized Representative Issue Date: 04/10/97 wc880001 INSURED'S COPY SOLICITATION OF COMMENTS FROM POLICYHOLDER THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA In addition to the notice requirement attached to this Workers' Compensation policy, we wish to inform you of our loss control programs available in the State of Texas. We have Field Safety Representatives with the experience and expertise to provide accident loss prevention services, at no additional charge, reasonably commensurate with the hazard, loss experience, size and nature of your business operation. Our services may include surveys, recommendations, training programs, consultations, analysis of accident causes, industrial hygiene and industrial health services related to your specific profession or industry. In the event you decide not to utilize our loss control services and opt to use your own safety department or hire an outside contractor, the service must be provided by qualified loss prevention representatives who are recognized by the State of Texas. If you elect not to utilize our loss control services you are required by Texas statute to provide us with the following information (on your company letterhead stationary, signed by an officer of your firm): /bullet/ Acknowledgment of our offer of loss control services and your written rejection. /bullet/ Your reasons for selection of an alternative. /bullet/ Your alternative loss control program, which must be reasonably commensurate with the risk. /bullet/ Verification of the qualification of those who will be performing your loss control services. /bullet/ Acknowledgment that quarterly summaries of activities outlined in your loss control program will be submitted to us for review. If you have any questions or wish to discuss this matter, contact our Texas Loss Control Service Coordinating Unit, AIG Consultants, Inc. at 1-800-221-0651. 53365WC (ED. 9-95) INSURED'S COPY THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA 70 PINE STREET NEW YORK, NEW YORK 10270 TEXAS NOTICE IMPORTANT NOTICE AVISO IMPORTANTE To obtain information or make a complaint: Para obtener informacion o para someter una queja: You may call the company's toll-free telephone Usted puede liamar al numero de telefono gratis de number for information or to make a complaint at: la compania para informacion o para someter una queja ai: 1-800-553-6938 1-800-553-6938 You may contact the Texas Department of Insurance Puede comunicarse con el Departamento de Seguros to obtain information on companies, coverages, de Texas para obtener informacion acerca de rights or complaints at: companias, coberturas, derechos o quejas al: 1-800-252-3439 1-800-252-3439 You may write the Texas Department of Insurance Puede escribir al Departamento de Seguros de Texas P.O. Box 149104 P.O. Box 149104 Austin, TX 78714-9104 Austin, TX 78714-9104 Fax# (512) 475-1771 Fax# (512) 475-1771 PREMIUM OR CLAIM DISPUTES: Should you have a DISPUTAS SOBRE PRIMAS 0 RECLAMOS: Si tiene una dispute concerning your premium or about a claim disputa concerniente a su prima o a un reclamo, you should contact the agent first. If the dispute debe comunicarse con el agente primero. Si no se is not resolved, you may contact the Texas Department resuelve la disputa, puede entonces comunicarse of Insurance. con el departamento (TDI). ATTACH THIS NOTICE TO YOUR POLICY: This notice is UNA ESTE AVISO A SU POLIZA: Este aviso es solo para for information only and does not become a part or proposito de informacion y no se convierte en condition of the attached document. parte o condicion del documento adjunto. 5369OWC (ED. 5-92) INSURED'S COPY NOTIFICATION TO POLICYHOLDERS OF ACCIDENT PREVENTION SERVICES THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA ____________ is required by law to provide its policyholders with certain accident prevention services as required by the Texas Labor Code, Section 411.066, at no additional cost. If you would like more information call our Texas Loss Control Service Coordinating Unit, AIG Consultants, Inc. at 1-800-221-0651. If you have any questions about this requirement, call the Division of Workers' Health and Safety, Texas Workers' Compensation Commission at 1-800-452-9595. WC 7738 (ED. 9-95) NOTIFICATION TO POLICYHOLDERS OF ACCIDENT PREVENTION SERVICES THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA ____________ is required by law to provide its policyholders with certain accident prevention services as required by the Texas Labor Code, Section 411.066, at no additional cost. If you would like more information call our Texas Loss Control Service Coordinating Unit, AIG Consultants, Inc. at 1-800-221-0651. If you have any questions about this requirement, call the Division of Workers' Health and Safety, Texas Workers' Compensation Commission at 1-800-452-9595. WC 7738 (ED. 9-95) INSURED'S COPY ISSUED BY THE STOCK INSURANCE COMPANY HEREIN CALLED THE COMPANY AGENT NUMBER POLICY NUMBER NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA 13072 49565 RM WC 217-79-43 INCORPORATED UNDER THE LAWS OF PENNSYLVANIA ITEM 1. NAMED INSURED: MAILING ADDRESS IDENTIFICATION NO. OUTSOURCE INTERNATIONAL, INC. [LOGO] Member Companies of 8000 NORTH FEDERAL HIGHWAY American International Group BOCA RATON FL 33487-0000 EXECUTIVE OFFICES: 70 PINE STREET, NEW YORK, N.Y. 10270 I.D.# 917-356254 PRODUCERS NAME & MAILING ADDRESS WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CENTURY FINANCIAL SERVICES INFORMATION PAGE 185 N W SPANISH RIVER BLVD 170 POB 811088 BOCA RATON FL 33481-1088 - -------------------------------------------------------------------------------- INSURED IS CORPORATION PREVIOUS POLICY NUMBER RMWC 2117626 (RENEWAL) - -------------------------------------------------------------------------------- OTHER WORKPLACES NOT SHOWN ABOVE - -------------------------------------------------------------------------------- ITEM 2 POLICY PERIOD 12:01 A.M. STANDARD TIME AT THE INSURED'S MAILING ADDRESS FROM 01/01/97 TO 01/01/98 - -------------------------------------------------------------------------------- ITEM 3 A. WORKERS COMPENSATION INSURANCE: PART ONE OF THE POLICY APPLIES TO WORKERS COMPENSATION LAW OF THE STATES LISTED HERE: UT WI ------------------------------------------------------------------------- B. EMPLOYERS LIABILITY INSURANCE: PART TWO OF THE POLICY APPLIES TO THE WORK IN EACH STATE LISTED IN ITEM 3.A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE: BODILY INJURY BY ACCIDENT $1,000,000 EACH ACCIDENT BODILY INJURY BY DISEASE $1,000,000 POLICY LIMIT BODILY INJURY BY DISEASE $1,000,000 EACH EMPLOYEE ------------------------------------------------------------------------- C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO THE STATES, IF ANY, LISTED HERE: NONE - -------------------------------------------------------------------------------- ITEM 4 THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, CLASSIFICATIONS, RATES AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. ------------------------------------------------------------------------- ESTIMATED TOTAL RATE PER ESTIMATED CLASSIFICATIONS CODE NUMBER REMUNERATION $100 OF RE- PREMIUM [X]ANNUAL [ ]3 YEAR NUMERATION [X]ANNUAL [ ]3 YEAR - -------------------------------------------------------------------------------- SEE ATTACHED SCHEDULES - -------------------------------------------------------------------------------- EXPENSE CONSTANT (EXCEPT WHERE APPLICABLE BY STATE) $160 WI - -------------------------------------------------------------------------------- MINIMUM PREMIUM $850 WI TOTAL ESTIMATED PREMIUM $207,159 - -------------------------------------------------------------------------------- Indicated below, interim adjustments of premium shall be made: [ ]Semi-Annually [ ]Quarterly [ ]Monthly DEPOSIT PREMIUM 207,159 - -------------------------------------------------------------------------------- ENDORSEMENTS (FORM NUMBER) SEE ATTACHED SCHEDULE - -------------------------------------------------------------------------------- 04/01/97 ATLANTA 07 - ------------------------------------------------- ISSUE DATE PRINT DATE: 04/02/97 ISSUING OFFICE ---------------------------------------- 39967 AUTHORIZED REPRESENTATIVE WC 00 00 01 INSURED'S COPY FORMS SCHEDULE Policy Number: RM WC 217-79-43 Effective Date: 01/01/97 - -------------------------------------------------------------------------------- WC000000A TERMS & CONDITIONS 53820 LARGE RISK RATING PLAN ENDT WC000106A USL&H WC ACT COVERAGE END. WC000301A ALTERNATE EMPLOYER ENDORSEMENT WC000311A VOL COMP & EL COVERAGE ENDT WC000402 ANNIVERSARY RATING DATE WC000403 EXPERIENCE RATING MOD FACTOR WC000414 NOTIFICATION OF CHG OWNERSHIP WC430301 STATUTORY EMPLOYEE EXCLUSION WC58977 UTAH FRAUD NOTICE 60549WC WI NOTICE TO POLICYHOLDER. WC480601B WISCONSIN LAW ENDORSEMENT WC880001 ST OF ME EXCL LW0418 (ED. 1-92) INSURED'S COPY WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY National Union Fire Insurance Company of Pittsburgh, Pa. [LOGO] American Home Assurance Company Member Companies of American International Group, Inc. The Insurance Company of EXECUTIVE OFFICES The State of Pennsylvania 70 PINE STREET NEW YORK, N.Y. 10270 Birmingham Fire Insurance Company of Pennsylvania Commerce and Industry Insurance Company Coverage is provided by the Company designated on the Information Page A Stock Insurance Company WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY QUICK REFERENCE BEGINNING ON PAGE Information Page..........................................................i GENERAL SECTION...........................................................1 A. The Policy........................................................1 B. Who Is Insured....................................................1 C. Workers Compensation Law..........................................1 D. State.............................................................1 E. Locations.........................................................1 PART ONE-WORKERS COMPENSATION INSURANCE...................................1 A. How This Insurance Applies........................................1 B. We Will Pay.......................................................1 C. We Will Defend....................................................1 D. We Will Also Pay..................................................1 E. Other Insurance...................................................2 F. Payments You Must Make............................................2 G. Recovery From Others..............................................2 H. Statutory Provisions..............................................2 THESE POLICY PROVISIONS WITH THE INFORMATION PAGE AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THIS POLICY. "INCLUDES COPYRIGHT MATERIAL OF THE NATIONAL COUNCIL ON COMPENSATION INSURANCE, USED WITH ITS PERMISSION. COPYRIGHT 1983 NATIONAL COUNCIL ON COMPENSATION INSURANCE" 39638C(04/92) WC 00 00 00 A (STANDARD) INSURED'S COPY ED 4 O2 QUICK REFERENCE - CONTINUED BEGINNING ON PAGE PART TWO - EMPLOYERS LIABILITY INSURANCE ................................ 2 A. How This Insurance Applies .................................. 2 B. We Will Pay ................................................. 3 C. Exclusions .................................................. 3 D. We Will Defend .............................................. 3 E. We Will Also Pay ............................................ 4 F. Other insurance ............................................. 4 G. Limits of Liability ......................................... 4 H. Recovery From Others ........................................ 4 I. Action Against Us ........................................... 4 PART THREE - OTHER STATES INSURANCE ..................................... 4 A. How This Insurance Applies .................................. 4 B. Notice ...................................................... 5 PART FOUR - YOUR DUTIES IF INJURY OCCURS ................................ 5 PART FIVE - PREMIUM ..................................................... 5 A. Our Manuals ................................................. 5 B. Classifications ............................................. 5 C. Remuneration ................................................ 5 D. Premium Payments ............................................ 5 E. Final Premium ............................................... 5 F. Records ..................................................... 6 G. Audit ....................................................... 6 PART SIX - CONDITIONS ................................................... 6 A. Inspection .................................................. 6 S. Long Term Policy ............................................ 6 C. Transfer of Your Rights and Duties .......................... 6 D. Cancellation ................................................ 6 E. Sole Representative ......................................... 6 IMPORTANT: This Quick Reference is not part of the Workers Compensation and Employers Liability Policy and does not provide coverage. Refer to the Workers Compensation and Employers Liability Policy itself for actual contractual provisions. PLEASE READ THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CAREFULLY INSURED'S COPY ATTACH FORM AND ENDORSEMENTS (IF ANY) HERE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows. GENERAL SECTION A. THE POLICY This policy includes at its effective date the Information Page and all endorsements and schedules listed there. It is a contract of insurance between you (the employer named in Item 1 of the Information Page) and us (the insurer named on the Information Page). The only agreements relating to this insurance are stated in this policy. The terms of this policy may not be changed or waived except by endorsement issued by us to be part of this policy. B. WHO IS INSURED You are insured if you are an employer named in Item 1 of the Information Page. If that employer is a partnership, and if you are one of its partners, you are insured, but only in your capacity as an employer of the partnership's employees. C. WORKERS COMPENSATION LAW Workers Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page. It includes any amendments to that law which are in effect during the policy period. It does not include any federal workers or workman's compensation law, any federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. D. STATE State means any state of the United States of America, and the District of Columbia. E. LOCATIONS This policy covers all of your workplaces listed in Items 1 or 4 of the Information Page; and it covers all other workplaces in Item 3.A states unless you have other insurance or are self-insured for such workplaces. PART ONE - WORKERS COMPENSATION INSURANCE A. HOW THIS INSURANCE APPLIES This workers compensation insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. Bodily injury by accident must occur during the policy period. 2. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. B. WE WILL PAY We will pay promptly when due the benefits required of you by the workers compensation law. C. We Will Defend We have the right and duty to defend at our expense any claim, proceeding or suit against you for benefits payable by this insurance. We have the right to investigate and settle these claims, proceedings or suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. D. We Will Also Pay We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding or suit we defend: 1. reasonable expenses incurred at our request, but not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amount payable under this insurance; WC 00 00 00 A 1 of 7 INSURED'S COPY 3. litigation costs taxed against you; 4. interest on a judgment as required by law until we offer the amount due under this insurance; and 5. expenses we incur. E. OTHER INSURANCE We will not pay more than our share of benefits and costs covered by this insurance and other insurance or self-insurance. Subject to any limits of liability that may apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance will be equal until the loss is paid. F. PAYMENTS YOU MUST MAKE You are responsible for any payments in excess of the benefits regularly provided by the workers compensation law including those required because: 1. of your serious and willful misconduct; 2. you knowingly employ an employee in violation of law; 3. you fail to comply with a health or safety law or regulation; or 4. you discharge, coerce or otherwise discriminate against any employee in violation of the workers compensation law. If we make any payments in excess of the benefits regularly provided by the workers compensation law on your behalf, you will reimburse us promptly. G. RECOVERY FROM OTHERS We have your rights, and the rights of persons entitled to the benefits of this insurance, to recover our payments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. H. Statutory Provisions These statements apply where they are required by law. 1. As between an injured worker and us, we have notice of the injury when you have notice. 2. Your default or the bankruptcy or insolvency of you or your estate will not relieve us of our duties under this insurance after an injury occurs. 3. We are directly and primarily liable to any person entitled to the benefits payable by this insurance. Those persons may enforce our duties; so may an agency authorized by law. Enforcement may be against us or against you and us. 4. Jurisdiction over you is jurisdiction over us for purposes of the workers compensation law. We are bound by decisions against you under that law, subject to the provisions of this policy that are not in conflict with that law. 5. This insurance conforms to the parts of the workers compensation law that apply to: a. benefits payable by this insurance or; b. special taxes, payments into security or other special funds, and assessments payable by us under that law. 6. Terms of this insurance that conflict with the workers compensation law are changed by this statement to conform to that law. Nothing in these paragraphs relieves you of your duties under this policy. PART TWO - EMPLOYERS LIABILITY INSURANCE A. HOW THIS INSURANCE APPLIES This employers liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must arise out of and in the course of the injured employee's employment by you. 2. The employment must be necessary or incidental to your work in a state or territory listed in Item 3.A. of the Information Page. 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. If you are sued, the original suit and any related legal actions for damages for bodily injury WC 00 00 00 A 2 of 7 INSURED'S COPY by accident or by disease must be brought in the United States of America, its territories or possessions, or Canada. B. WE WILL PAY We will pay all sums you legally must pay as damages because of bodily injury to your employees, provided the bodily injury is covered by this Employers Liability Insurance. The damages we will pay, where recovery is permitted by law, include damages: 1. for which you are liable to a third party by reason of a claim or suit against you by that third party to recover the damages claimed against such third party as a result of injury to your employee; 2. for care and loss of services; and 3. for consequential bodily injury to a spouse, child, parent, brother or sister of the injured employee; provided that these damages are the direct consequence of bodily injury that arises out of and in the course of the injured employee's employment by you; and 4. because of bodily injury to your employee that arises out of and in the course of employment, claimed against you in a capacity other than as employer. C. EXCLUSIONS This insurance does not cover: 1. liability assumed under a contract. This exclusion does not apply to a warranty that your work will be done in a workmanlike manner; 2. punitive or exemplary damages because of bodily injury to an employee employed in violation of law; 3. bodily injury to an employee while employed in violation of law with your actual knowledge or the actual knowledge of any of your executive officers; 4. any obligation imposed by a workers compensation, occupational disease, unemployment compensation, or disability benefits law, or any similar law; 5. bodily injury intentionally caused or aggravated by you; 6. bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America or Canada who is temporarily outside these countries; 7. damages arising out of coercion, criticism, demotion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimination against or termination of any employee, or any personnel practices, policies, acts or omissions. 8. bodily injury to any person in work subject to the Longshore and Harbor Workers' Compensation Act (33 USC Sections 901-950), the Nonappropriated Fund Instrumentalities Act (5 USC Sections 8171-8173), the Outer Continental Shelf Lands Act (43 USC Sections 1331-1356), the Defense Base Act (42 USC Sections 1651-1654), the Federal Coal Mine Health and Safety Act of 1969 (30 USC Sections 901-942), any other federal workers or workmen's compensation law or other federal occupational disease law, or any amendments to these laws. 9. bodily injury to any person in work subject to the Federal Employers' Liability Act (45 USC Sections 51-60), any other federal laws obligating an employer to pay damages to an employee due to bodily injury arising out of or in the course of employment, or any amendments to those laws. 10. bodily injury to a master or member of the crew of any vessel. 11. fines or penalties imposed for violation of federal or state law. 12. damages payable under the Migrant and Seasonal Agricultural Worker Protection Act (29 USC Sections 1801-1872) and under any other federal law awarding damages for violation of those laws or regulations issued thereunder, and any amendments to those laws. D. WE WILL DEFEND We have the right and duty to defend, at our expense, any claim, proceeding or suit against you for damages payable by this insurance. We have the right to investigate and settle these claims, proceedings and suits. WC 00 00 00 A 3 of 7 INSURED'S COPY We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. We have no duty to defend or continue defending after we have paid our applicable limit of liability under this insurance. E. WE WILL ALSO PAY We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim proceeding, or suit we defend; 1. reasonable expenses incurred at our request; but not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the limit of our liability under this insurance; 3. litigation costs taxed against you; 4. interest on a judgment as required by law until we offer the amount due under this insurance; and 5. expenses we incur. F. OTHER INSURANCE We will not pay more than our share of damages and costs covered by this insurance and other insurance or self-insurance. Subject to any limits of liability that apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance and self-insurance will be equal until the loss is paid. G. LIMITS OF LIABILITY Our liability to pay for damages is limited. Our limits of liability are shown in Item 3.B. of the Information Page. They apply as explained below. 1. Bodily Injury by Accident. The limit shown for "bodily injury by accident-each accident" is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident. A disease is not bodily injury by accident unless it results directly from bodily injury by accident. 2. Bodily Injury by Disease. The limit shown for "bodily injury by disease-policy limit" is the most we will pay for all damages covered by this insurance and arising out of bodily injury by disease, regardless of the number of employees who sustain bodily injury by disease. The limit shown for "bodily injury by disease each employee" is the most we will pay for all damages because of bodily injury by disease to any one employee. Bodily injury by disease does not include disease that results directly from a bodily injury by accident. 3. We will not pay any claims for damages after we have paid the applicable limit of our liability under this insurance. H. RECOVERY FROM OTHERS We have your rights to recover our payment from anyone liable for an injury covered by this insurance. You will do everything necessary to protect those rights for us and to help us enforce them. I. ACTIONS AGAINST US There will be no right of action against us under this insurance unless: 1. You have complied with all the terms of this policy; and 2. The amount you owe has been determined with our consent or by actual trial and final judgment. This insurance does not give anyone the right to add us as a defendant in an action against you to determine your liability. The bankruptcy or insolvency of you or your estate will not relieve us of our obligations under this Part. PART THREE - OTHER STATES INSURANCE A. HOW THIS INSURANCE APPLIES 1. This other states insurance applies only if one or more states are shown in Item 3.C. of the Information Page. 2. If you begin work in any one of those states after the effective date of this policy and are not insured or are not self-insured for such work, all provisions of the policy will apply as though that state were listed in Item 3.A. of the Information Page. 3. We will reimburse you for the benefits required by the workers compensation law of that state if we are not permitted to pay the benefits directly to persons entitled to them. 4. If you have work on the effective date of this policy in any state not listed in Item 3.A. of the WC 00 00 00 A 4 of 7 INSURED'S COPY Information Page, coverage will not be afforded for that state unless we are notified within thirty days. B. NOTICE Tell us at once if you begin work in any state listed in Item 3.C. of the Information Page. PART FOUR - YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered by this policy. Your other duties are listed here. l. Provide for immediate medical and other services required by the workers compensation law. 2. Give us or our agent the names and addresses of the injured persons and of witnesses, and other information we may need. 3. Promptly give us all notices, demands and legal papers related to the injury, claim, proceeding or suit. 4. Cooperate with us and assist us, as we may request, in the investigation, settlement or defense of any claim, proceeding or suit. 5. Do nothing after an injury occurs that would interfere with our right to recover from others. 6. Do not voluntarily make payments, assume obligations or incur expenses, except at your own cost. PART FIVE - PREMIUM A. OUR MANUALS All premium for this policy will be determined by our manuals of rules, rates, rating plans and classifications. We may change our manuals and apply the changes to this policy if authorized by law or a governmental agency regulating this insurance. B. CLASSIFICATIONS Item 4 of the Information Page shows the rate and premium basis for certain business or work classifications. These classifications were assigned based on an estimate of the exposures you would have during the policy period. If your actual exposures are not properly described by those classifications, we will assign proper classifications, rates and premium basis by endorsement to this policy. C. REMUNERATION Premium for each work classification is determined by multiplying a rate times a premium basis. Remuneration is the most common premium basis. This premium basis includes payroll and all other remuneration paid or payable during the policy period for the services of: 1. All your officers and employees engaged in work covered by this policy; and 2. All other persons engaged in work that could make us liable under Part One (Workers Compensation Insurance) of this policy. If you do not have payroll records for these persons, the contract price for their services and materials may be used as the premium basis. This paragraph 2 will not apply if you give us proof that the employers of these persons lawfully secured their workers compensation obligations. D. PREMIUM PAYMENTS You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. E. FINAL PREMIUM The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the balance. If it is less, we will refund the balance to you. The final premium will not be less than the highest minimum premium for the classifications covered by this policy. If this policy is canceled, final premium will be determined in the following way unless our manuals provide otherwise. 1. If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. 2. If you cancel, final premium will be more than pro rata; it will be based on the time this policy was in force, and increased by our short rate WC 00 00 00 A 5 of 7 INSURED'S COPY cancellation table and procedure. Final premium will not be less than the minimum premium. F. RECORDS You will keep records of information needed to compute premium. You will provide us with copies of those records when we ask for them. G. AUDIT You will let us examine and audit all your records that relate to this policy. These records include ledgers, journals, registers, vouchers, contracts, tax reports, payroll and disbursement records, and programs for storing and retrieving data. We may conduct the audits during regular business hours during the policy period and within three years after the policy period ends. Information developed by audit will be used to determine final premium. Insurance rate service organizations have the same rights we have under this provision. PART SIX - CONDITIONS A. INSPECTION We have the right, but are not obliged to inspect your workplaces at any time. Our inspections are not safety inspections. They relate only to the insurability of the workplaces and the premiums to be charged. We may give you reports on the conditions we find. We may also recommend changes. While they may help reduce losses, we do not undertake to perform the duty of any person to provide for the health or safety of your employees or the public. We do not warrant that your workplaces are safe or healthful or that they comply with laws, regulations, codes or standards. Insurance rate service organizations have the same rights we have under this provision. B. LONG TERM POLICY If the policy period is longer than one year and sixteen days, all provisions of this policy will apply as though a new policy were issued on each annual anniversary that this policy is in force. C. TRANSFER OF YOUR RIGHTS AND DUTIES Your rights or duties under this policy may not be transferred without our written consent. If you die and we receive notice within thirty days after your death, we will cover your legal representative as insured. D. CANCELLATION 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancellation is to take effect. 2. We may cancel this policy. We must mail or deliver to you not less than ten days advance written notice stating when the cancellation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 3. The policy period will end on the day and hour stated in the cancellation notice. 4. Any of these provisions that conflicts with a law that controls the cancellation of the insurance in this policy is changed by this statement to comply with that law. E. SOLE REPRESENTATIVE The insured first named in Item 1 of the Information Page will act on behalf of all insureds to change this policy, receive return premium, and give or receive notice of cancellation. WC 00 00 00 A 6 of 7 INSURED'S COPY In WITNESS WHEREOF, the company has caused this policy to be executed and attested, but this policy shall not be valid unless countersigned by a duly authorized representative of the company. /s/ WILLIAM D. SMITH /s/ [ILLEGIBLE] -------------------- --------------- President President The Insurance Company National Union Fire of The State of Pennsylvania Insurance Company of Birmingham Fire Insurance Pittsburgh, PA Company of Pennsyivania /s/ WALTER L. MOONEY /s/ [ILLEGIBLE] -------------------- --------------- President President Commerce and Industry American Home Insurance Company Assurance Company /s/ ELIZABETH M. TUCK --------------------- Secretary National Union Fire Insurance Company of Pittsburgh, PA American Home Assurance Company The Insurance Company of The State of Pennsylvania Birmingham Fire Insurance Company of Pennsylvania Commerce and Industry insurance Company WC 00 00 00 A 7 of 7 INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-43 UTAH - ------------------- -------- ------------------------------ POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS SPECIFICALLY PROVIDED CODE ESTIMATED TOTAL PER $100 OF ESTIMATED ELSEWHERE IN THIS POLICY, DO NOT MODIFY ANY OF THE NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS OTHER PROVISIONS OF THIS POLICY. OUTSOURCE INTERNATIONAL, INC. 8000 NORTH FEDERAL HIGHWAY BOCA RATON, FL 33487 CLERICAL OFFICE EMPLOYEES NOC 8810 394,000 0.31 1,221 UNMODIFIED PREMIUM 1,221 INCREASE LIMITS-EMPLOYER LIABILITY 3.3% 9812 1,261 TOTAL UNMODIFIED PREMIUM 40 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 (265) MODIFIED STANDARD PREMIUM 996 UNDISCOUNTED PREMIUM 996 TOTAL ESTIMATED ANNUAL PREMIUM 996 TOTAL DUE 996 - -------------------------------------------------------------------------------------------------------------------------- WC 7754 (ED. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-43 WISCONSIN - ------------------ --------- ------------------------------ POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------ INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS SPECIFICALLY PROVIDED CODE ESTIMATED TOTAL PER $100 OF ESTIMATED ELSEWHERE IN THIS POLICY, DO NOT MODIFY ANY OF NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THE OTHER PROVISIONS OF THIS POLICY. OUTSOURCE INTERNATIONAL, INC. 8000 NORTH FEDERAL HIGHWAY BOCA RATON, FL 33487 STORES-HARDWARE-RETAIL-INCLUDING DRIVERS 8010 16,700 2.24 374 LABOR WORLD OF AMERICA, INC. 2033 LATHROP AVENUE RACINE, WI 53405 FARM: NURSERY EMPLOYEES & DRIVERS 0005 24,100 5.36 1,292 INCLUDES INCIDENTAL LANDSCAPE GARDENING FLORIST & DRIVERS 0035 1,600 3.04 49 LANDSCAPE GARDENING & DRIVERS 0042 22,100 8.82 1,949 CEMENT MFG 1701 2,300 9.25 213 BAKERY & DRIVERS, ROUTE SUPERVISORS 2003 23,600 4.82 1,138 CONFECTION MFG 2041 1,400 5.25 74 PACKING HOUSE - ALL OPERATIONS NPD 2089 150 6.22 9 MEAT PRODUCTS MFG NOC 2095 1,456,300 6.60 96,116 CANNERIES 2111 3,000 4.45 134 TEXTILE FIBER MFG - SYNTHETIC 2305 18,600 2.23 415 LEATHERS--WASHING STEAMING, CLEANING 2585 900 4.56 41 AND RENOVATING PIPE OR TUBE MFG NOC & DRIVERS 3022 14,600 6.04 882 IRON WORKS - SHOP - DECORATIVE 3041 7,300 4.31 315 FOUNDRIES MFG 3145 29,100 3.21 934 - -------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-43 WISCONSIN - ------------------ ---------- ------------------------------ POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------- INTRA/INDEPENDENT STATE RISK ID - --------------------------------------------------------------------------------------------------------------------------- ITEM-4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - --------------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS SPECIFICALLY CODE ESTIMATED TOTAL PER PER $100 OF ESTIMATED PROVIDED ELSEWHERE IN THIS POLICY, DO NOT MODIFY NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUM ANY OF THE OTHER PROVISIONS OF THIS POLICY. ELECTRICAL APPARATUS MFG NOC 3179 90,700 3.75 3,401 WIRE GOODS MFG NOC 3257 6,500 5.12 333 HEAT TREATING-METAL-N P D 3307 3,200 8.51 272 WATCH MFG 3385 13,700 2.63 360 METAL STAMPING MFG 3400 73,900 5.37 3,968 APPLICABLE TO MASS PRODUCTION MANUFACTURING OF STAMPED METAL ARTICLES INCLUDING, BUT NOT LIMITED TO, LICENSE PLATES, TAGS, TOYS,PIE PLATES, BUCKETS AND WASTE BASKETS. AGRICULTURAL OR CONSTRUCTION MACHINERY MFG 3507 17,800 5.32 947 A___ MFG NOC 3548 30,600 2.79 854 PUMP MFG 3612 44,400 3.72 1,652 MACHINE SHOP NOC 3632 179,600 3.44 6,178 ELECTRIC POWER OR TRANSMISSION EQUIPMENT 3643 6,000 3.33 200 MFG AUTOMOBILE RADIATOR MFG NPD 3807 1,300 3.96 51 AUTOMOBILE MFG 3808 5,200 3.44 179 PAPER MFG 4239 1,000 2.45 25 PAPER GOODS MFG. NOC 4279 318,600 2.91 9,271 PRINTING 4299 29,600 2.63 778 B0OKBINDING 4307 7,800 3.20 250 RUBBER GOODS MFG N0C 4410 31,300 4.45 1,393 PLASTICS-FABRICATED PRODUCTS MFG N0C 4452 33,200 4.02 1,335 ___ICS MFG: SHEETS RODS OR TUBES 4459 88,400 3.76 3,324 - ---------------------------------------------------------------------------------------------------------------------------- WC 7764 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-43 WISCONSIN - ------------------ ---------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------- INTRA/INDEPENDENT STATE RISK ID - --------------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - --------------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS SPECIFICALLY CODE ESTIMATED TOTAL PER $100 OF ESTIMATED PROVIDED ELSEWHERE IN THIS POLICY, DO NOT MODIFY NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PERMIUMS ANY OF THE OTHER PROVISIONS OF THIS POLICY. PLASTICS MFG: MOLDED PRODUCTS NOC 4484 83,500 3.59 2,998 PHARMACEUTICAL OR SURGICAL GOODS MFG NOC 4693 6,500 1.69 110 GRANDSTANDS OR BLEACHERS ERECTION- 5102 1,000 12.27 123 PORTABLE-METAL FURNITURE OR FIXTURES INSTALLATION - 5146 11,100 6.80 775 PORTABLE - NOC PLUMBING NOC & DRIVERS 5183 3,000 5.74 172 CARPENTRY - INSTALLATION OF FINISHED 5437 6,800 8.32 566 WOODEN FLOORING SHEET ROCK INSTALLATION - WITHIN 5445 5,300 8.48 449 BUILDINGS - & DRIVERS TMEKEEPERS-CONSTRUCTION OR ERECTION 5610 1,180,500 5.16 60,914 FOOD SUNDRIES MFG.N 0 C -NO CEREAL 6504 12,300 4.31 530 MILLING FIRE EXTINGUISHING SYSTEMS-DRY CHEMICAL- 7380 29,500 5.42 1,599 SERVICE STORE RISKS- RETAIL- N.O.C. 8017 14,100 1.62 228 STORE RISKS- WHOLESALE, OR COMBINED 8018 89,300 3.92 3,501 WHOLESALE AND RETAIL- N.O.C. FURNITURE STORES --WHOLESALE OR RETAIL 8044 9,200 2.99 275 & DRIVERS BUILDING MATERIAL DEALER - NEW MATERIALS 8058 300 3.06 9 ONLY: STORE EMPLOYEES MACHINERY DEALER NOC - STORE OR YARD- 8107 19,700 4.04 796 & DRIVERS VEGETABLE PACKING & SALESMEN, DRIVERS 8209 3,000 5.93 178 BUILDING MATERIAL DEALER - NEW MATERIALS 8232 22,500 5.66 1,274 - -------------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-43 WISCONSIN - ------------------- --------- -------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID -------------------------------- INTRA/INDEPENDENT STATE RISK ID - ----------------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ----------------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS SPECIFICALLY CODE ESTIMATED TOTAL PER $100 OF ESTIMATED PROVIDED ELSEWHERE IN THIS POLICY, DO NOT MODIFY NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS ANY OF THE OTHER PROVISIONS OF THIS POLICY. 0NLY: ALL OTHER EMPLOYEES YARD, WAREHOUSE, DRIVERS RUBBER STOCK DEALER USED - AND DRIVERS NPD 8264 85,900 10.58 9,088 IRON SCRAP DEALER NPD 8265 17,300 12.66 2,190 STORAGE WAREHOUSE - COLD 8291 16,000 4.00 640 TORAGE WAREHOUSE NOC 8292 133,700 6.36 8,503 STORAGE WAREHOUSE - FURNITURE - & 8293 44,700 12.66 5,659 DRIVERS GASOLINE OR OIL SUPPLY STATIONS- 8387 400 3.65 15 MAINTENANCE BY LESSORS: ___S REVIEWS THE CLASSIFICATION ASSIGNMENT OF EMPLOYEES OF OIL AND GASOLINE DISTRIBUTING COMPANIES ENGAGED IN MAINTAINING GASOLINE OR OIL SUPPLY STATIONS OWNED BY SUCH COMPANIES BUT LEASED TO OTHERS FOR OPERATION. THE WORK OF THESE EMPLOYEES INVOLVES SUCH OPERATIONS AS THE MINOR ADJUSTMENT, REPAIR AND CLEANING OF AIR COMPRESSORS, GASOLINE PUMPS AND OTHER MECHANICAL EQUIPMENT; INSPECTION OF PREMISES; MAINTENANCE OF LAVORATORIES; PAINTING THE INTERIOR AND EXTERIOR OF THE BUILDINGS; AND IN GENERAL KEEPING THE PREMISES IN AN ATTRACTIVE CONDITION. THEIR WORK DOES NOT INVOLVE ANY NEW CONSTRUCTION OR ALTERATION WORK ON BUILDINGS; NOR TO ANY APPRECIABLE DEGREE, THE INSTALLATION OF GASOLINE PUMPS AND TANKS SINCE SUCH WORK IS LET TO CONTRACTORS SPECIALIZING IN IT. CONSIDERATION HAS BEEN GIVEN TO THESE MAINTENANCE ACTIVITIES, AND IT IS THE RULING THAT THE OPERATIONS IN QUESTION ARE ESSENTIALLY THE SAME AS THOSE CONDUCTED IN COMPANY OWNED AND OPERATED STATIONS AND THEREFORE, ARE PROP- - --------------------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-43 WISCONSIN - ------------------ --------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOVMENT ID ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS SPECIFICALLY CODE ESTIMATED TOTAL PER $100 OF ESTIMATED PROVIDED ELSEWHERE IN THIS POLICY, DO NOT MODIFY NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PERMIUMS ANY OF THE OTHER PROVISIONS OF THIS POLICY. ERLY ASSIGNABLE, BY ANALOGY, TO CLASSIFICATION 8380--"GASOLINE- STATIONS--RETAIL--& DRIVERS." AUTOMOBILE STORAGE GARAGE OR PARKING 8392 68,800 2.19 1,507 STATION & DRIVERS SALESPERSONS, COLLECTORS OR MESSENGERS- 8742 106,500 0.68 724 OUTSIDE CLERICAL OFFICE EMPLOYEES NOC 8810 1,361,700 0.27 3,677 RETIREMENT LIVING CENTERS: 8826 900 3.00 27 ALL OTHER EMPLOYEES & SALESPERSONS, DRIVERS BUILDINGS--OPERATIONS BY CONTRACTORS 9014 16,600 4.47 742 ____ER 9079 900 2.31 21 RELIGIOUS ORGANIZATION: 9101 3,400 3.67 125 ALL OTHER EMPLOYEES LAWN MAINTENANCE - COMMERCIAL OR 9102 71,400 4.32 3,084 DOMESTIC & DRIVERS CODES 9102 AND 0042, LANDSCAPE GARDENING AND DRIVERS MAY BE ASSIGNED TO THE SAME RISK. THE PAYROLL OF AN INDIVIDUAL EMPLOYEE MAY BE DIVIDED AND ALLOCATED BETWEEN CODES 0042 AND 9102 PROVIDED THAT THE ENTRIES ON THE ORIGINAL RECORDS OF THE INSURED DISCLOSE AN ALLOCATION OF EACH INDIVIDUAL'S PAYROLL. AN ESTIMATE OR PERCENTAGE ALLOCATION OF PAYROLL IS N0T PERMITTED. AMUSEMENT PARKS OR EXHIBITIONS 9180 1,200 8.63 104 ___SHES, GARBAGE OR REFUSE COLLECTION & 9403 28,200 10.78 3,040 DRIVERS PAINTING: SHOP ONLY & DRIVERS NPD 9501 2,200 4.73 104 - ----------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-43 WISCONSIN - ------------------ --------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ----------------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ----------------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS SPECIFICALLY CODE ESTIMATED TOTAL PER $100 OF ESTIMATED PROVIDED ELSEWHERE IN THIS POLICY, DO NOT MODIFY NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS ANY OF THE OTHER PROVISIONS OF THIS POLICY. UNMODIFIED PREMIUM 252,433 INCREASED LIMITS-EMPLOYER LIABILITY 3.3% 9812 8,330 TOTAL UNMODIFIED PREMIUM 260,763 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 (54,760) MODIFIED STANDARD PREMIUM 206,003 UNDISCOUNTED PREMIUM 206,003 EXPENSE CONSTANT 0900 160 TOTAL ESTIMATED ANNUAL PREMIUM 206,163 TOTAL DUE 206,163 - ----------------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY LARGE RISK RATING PLAN ENDORSEMENT (SHORT FORM) This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-43 Issued to OUTSOURCE INTERNATIONAL, INC. By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. The premium for this policy will be determined according to the Large Risk Rating Plan Endorsement attached to policy No.RMWC2177940 53820 COUNTERSIGNED BY ________________________________ (ED. 07-92) AUTHORIZED REPRESENTATIVE INSURED'S COPY LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE ENDORSEMENT This endorsement changes the policy to which it is atttached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-43 Issued to OUTSOURCE INTERNATIONAL, INC. By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. This endorsement applies only to work subject to the Longshore and Harbor Workers' Compensation Act in a state shown in the Schedule. The policy applies to that work as though that state were listed in Item 3.A. of the Information Page. General Section C. WORKERS' COMPENSATION LAW is replaced by the following: C. WORKERS' COMPENSATION LAW Workers' Compensation Law means the workers or workman's compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page and the Longshore and Harbor Workers' Compensation Act (33 USC Sections 901-950). It includes any amendments to those laws that are in effect during the policy period. It does not include any other federal workers or workmen's compensation law, other federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. Part Two (Employers Liability Insurance), C. Exclusions., exclusion 8, does not apply to work subject to the Longshore and Harbor Workers' Compensation Act. This endorsement does not apply to work subject to the Defense Base Act, the Outer Continental Shelf Lands Act, or the Nonappropriated Fund Instrumentalities Act. Schedule STATE LONGSHORE AND HARBOR WORKERS' - ----- COMPENSATION ACT COVERAGE PERCENTAGE ------------------------------------ UTAH 105.00 WISCONSIN 40.00 The rates for classifications with code numbers not followed by the letter "F" are rates for work not ordinarily subject to the Longshore and Harbor Workers' Compensation Act. If this policy covers work under such classifications, and if the work is subject to the Longshore and Harbor Workers' Compensation Act, those non-F classification rates will be increased by the Longshore and Harbor Workers' Compensation Act Coverage Percentage shown in the Schedule. WC 00 01 06 A COUNTERSIGNED BY ________________________________ (ED. 04-92) AUTHORIZED REPRESENTATIVE INSURED'S COPY ALTERNATE EMPLOYER ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-43 Issued to OUTSOURCE INTERNATIONAL, INC. By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. This endorsement applies only with respect to bodily injury to your employees while in the course of special or temporary employment by the alternate employer in the state named in Item 2 of the Schedule. Part One (Workers Compensation Insurance) and Part Two (Employers Liability Insurance) will apply as though the alternate employer is insured. If an entry is shown in Item 3 of the Schedule the insurance afforded by this endorsement applies only to work you perform under the contract or at the project named in the Schedule. Under Part One (Workers Compensation Insurance) we will reimburse the alternate employer for the benefits required by the workers compensation law if we are not permitted to pay the benefits directly to the persons entitled to them. The insurance afforded by this endorsement is not intended to satisfy the alternate employer's duty to secure its obligations under the workers compensation law. We will not file evidence of this insurance on behalf of the alternate employer with any government agency. We will not ask any other insurer of the alternate employer to share with us a loss covered by this endorsement. Premium will be charged for your employees while in the course of special or temporary employment by the alternate employer. The policy may be cancelled according to its terms without sending notice to the alternate employer. Part Four (Your Duties If Injury Occurs) applies to you and the alternate employer. The alternate employer will recognize our right to defend under Parts One and Two and our right to inspect under Part Six. SCHEDULE 1. ALTERNATE EMPLOYER ADDRESS 2. STATE OF SPECIAL OR TEMPORARY EMPLOYMENT 3. CONTRACT OR PROJECT "ANY CLIENT IS INCLUDED AS AN ALTERNATE EMPLOYER AS RESPECTS THE USE OF TEMPORARY OR LEASED EMPLOYEES OF OUTSOURCE INTERNATIONAL AND AFFILIATED RELATED COMPANIES PER WRITTEN AGREEMENT BETWEEN THE PARTIES PRIOR TO LOSS." WC 00 03 01 A COUNTERSIGNED BY ________________________________ (ED. 02-89) AUTHORIZED REPRESENTATIVE INSURED'S COPY VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-43 Issued to OUTSOURCE INTERNATIONAL, INC. By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. This endorsement adds Voluntary Compensation Insurance to the policy. A. HOW THIS INSURANCE APPLIES This insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must be sustained by an employee included in the group of employees described in the Schedule. 2. The bodily injury must arise out of and in the course of employment necessary or incidental to work in a state listed in the Schedule. 3. The bodily injury must occur in the United States of America, its territories or possessions, or Canada, and may occur elsewhere if the employee is a United States or Canadian citizen temporarily away from those places. 4. Bodily injury by accident must occur during the policy period. 5. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. B. WE WILL PAY We will pay an amount equal to the benefits that would be required of you if you and your employees described in the Schedule were subject to the workers compensation law shown in the Schedule. We will pay those amounts to the persons who would be entitled to them under the law. C. EXCLUSIONS This insurance does not cover: 1. any obligation imposed by a workers compensation or occupational disease law, or any similar law. 2. bodily injury intentionally caused or aggravated by you. D. BEFORE WE PAY Before we pay benefits to the persons entitled to them, they must: 1. Release you and us, in writing, of all responsibility for the injury or death. 2. Transfer to us their right to recover from others who may be responsible for the injury or death. 3. Cooperate with us and do everything necessary to enable us to enforce the right to recover from others. If the persons entitled to the benefits of this insurance fail to do those things, our duty to pay ends at once. If they claim damages from you or from us for the injury or death, our duty to pay ends at once. WC 00 03 11 A (ED. 8-91) Page 1 of 2 INSURED'S COPY E. RECOVERY FROM OTHERS If we make a recovery from others, we will keep an amount equal to our expenses of recovery and the benefits we paid. We will pay the balance to the persons entitled to it. If the persons entitled to the benefits of this insurance make a recovery from others, they must reimburse us for the benefits we paid them. F. EMPLOYERS LIABILITY INSURANCE Part Two (Employers Liability Insurance) applies to bodily injury covered by this endorsement as though the State at employment shown in the Schedule were shown in Item 3.A of the Information Page. Schedule DESIGNATED WORKERS EMPLOYEES STATE OF EMPLOYMENT COMPENSATION LAW - --------- ------------------- ---------------- ALL OFFICERS AND ALL STATES EXCEPT STATE OF HIRE EMPLOYEES NOT SUBJECT AL, AZ, IA, IN, KY, LA TO THE WORKERS COMPENSATION MA, MI, MN, M0, MS, NE LAW EXCEPT MASTERS OR MEMBERS NH, NM, NY, PA, SC, TN OF THE CREW OF ANY VESSEL MD, VA, CA, ID, OR This endorsement does not apply in New Jersey, Nevada, North Dakota, Ohio, Washington, Wisconsin, West Virginia, Wyoming, and Maine. WC 00 03 11 A COUNTERSIGNED BY ________________________________ (ED. 8-91) AUTHORIZED REPRESENTATIVE Page 2 of 2 INSURED'S COPY ANNIVERSARY RATING DATE ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-43 Issued to OUTSOURCE INTERNATIONAL, INC. By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. The premium and rates for this policy, and the experience rating modification factor, if any, may change on your anniversary rating date shown in the Schedule. SCHEDULE ANNIVERSARY RATING DATE MAY (MONTH) 01 (DAY) WC 00 04 02 COUNTERSIGNED BY ________________________________ (ED. 4-M) AUTHORIZED REPRESENTATIVE INSURED'S COPY EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-43 Issued to OUTSOURCE INTERNATIONAL, INC. By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. The premium for the policy will be adjusted by an experience rating modification factor. The factor was not available when the policy was issued. The factor, if any, shown on the Information Page is an estimate. We will issue an endorsement to show the proper factor, if different from the factor shown, when it is calculated. WC 00 04 03 COUNTERSIGNED BY ________________________________ (ED. 4-84) AUTHORIZED REPRESENTATIVE INSURED'S COPY NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-43 Issued to OUTSOURCE INTERNATIONAL, INC. By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. Experience rating is mandatory for all eligible insureds. The experience rating modification factor, if any, applicable to this policy, may change if there is a change in your ownership or in that of one or more of the entities eligible to be combined with you for experience rating purposes. Change in ownership includes sales, purchases, other transfers, mergers, consolidations, dissolutions, formations of a new entity and other changes provided for in the applicable experience rating plan manual. You must report any change in ownership to us in writing within 90 days of such change. Failure to report such changes within this period may result in revision of the experience rating modification factor used to determine your premium. THIS ENDORSEMENT IS NOT APPLICABLE IN NEW JERSEY, PENNSYLVANIA, MICHIGAN, ALASKA, CALIFORNIA, DELAWARE, MAINE OR TEXAS. WC 00 04 14 COUNTERSIGNED BY ________________________________ (ED. 07-90) AUTHORIZED REPRESENTATIVE INSURED'S COPY UTAH STATUTORY EMPLOYEE EXCLUSION ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-43 Issued to OUTSOURCE INTERNATIONAL, INC. By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. This endorsement applies only to the insurance provided by the policy because Utah is shown in Item 3.A. of the Information Page. Part One (Workers Compensation Insurance), Part Two (Employers Liability Insurance), Part Three (Other States Insurance) and Part Four (Your Duties If Injury Occurs) of the policy do not apply to the insurance provided by the policy. The policy provides no insurance, and no cost is included for the assumption of risk. A premium will be charged to administer and service the policy. The policy is issued in accordance with he provisions of Utah law that authorize exceptions to the application of the statutory employer and statutory employee laws. A copy of this endorsement along with a copy of the Information Page showing the endorsement number in Item 3.D. will serve as evidence of a policy pursuant to 35-1-42(6)(c)(ii) and 35-1-42(6)(e)(ii) of the Utah Code. The insured named in Item 1 of the Information Page certifies that it is a partnership, corporation or sole proprietorship customarily engaged in an independently established trade, occupation, profession or business with no employees other than the partners, corporate officer or officers, or owner. As of the effective date of the policy, I, a partner, corporate officer or owner of the insured name in Item 1 of the Information Page, personally waive my entitlement to the benefits provided by the Utah Workers Compensation Act and the Utah Occupational Disease Act in the operation of the partnership, corporation or sole proprietorship and in the operation of the partnership's, corporation's or sole proprietorship's enterprise under a contract of hire for services. - --------------------------------------- --------------------- ---------- Signature of Partner, Corporate Officer Printed Name Date or Owner - --------------------------------------- --------------------- ---------- Signature of Additional Partners or Printed Name Date Corporate Officers - --------------------------------------- --------------------- ---------- Signature of Additional Partners or Printed Name Date Corporate Officers - --------------------------------------- --------------------- ---------- Signature of Additional Partners or Printed Name Date Corporate Officers FOR YOUR PROTECTION, UTAH LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT UNDERWRITING INFORMATION, FILES OR CAUSES TO BE FILED A FALSE OR FRAUDULENT CLAIM FOR DISABILITY COMPENSATION OR MEDICAL BENEFITS, OR SUBMITS A FALSE OR FRAUDULENT REPORT OR BILLING FOR HEALTH CARE FEES OR OTHER PROFESSIONAL SERVICES IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN THE STATE PRISON. This endorsement must be signed by each partner or corporate officer or owner who is waiving his or her entitlement to benefits. Attach additional copies of the endorsement if additional signatures are required. WC 43 03 01 COUNTERSIGNED BY ________________________________ (ED. 5-96) AUTHORIZED REPRESENTATIVE INSURED'S COPY UTAH FRAUD NOTICE FOR YOUR protection, Utah House Bill 249, requires the following to appear on your policy: "ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT UNDERWRITING INFORMATION, FILES OR CAUSES TO BE FILED A FALSE OR FRAUDULENT CLAIM FOR DISABILITY COMPENSATION OR MEDICAL BENEFITS, OR SUBMITS A FALSE OR FRAUDULENT REPORT OR BILLING FOR HEALTH CARE FEES OR OTHER PROFESSIONAL SERVICES IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN A STATE PRISON." WC 58977 (ED. 10-93) INSURED'S COPY WISCONSIN NOTICE TO POLICYHOLDER Loss records are maintained for your worker's compensation policy and are available on an annual basis upon written request. When requesting this data, please include the policy numbers and dates for the periods desired. Available records will be forwarded to you within 30 days of our receipt of your request. 60549WC COUNTERSIGNED BY ________________________________ (ED. 06-94) AUTHORIZED REPRESENTATIVE INSURED'S COPY WISCONSIN LAW ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-43 Issued to OUTSOURCE INTERNATIONAL, INC. By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. This endorsement applies only to the insurance provide by the policy because Wisconsin is shown in Item 3.A. of the Information Page. This policy is amended to reflect the following changes and/or additions to clarify or comply with Wisconsin Law: I. If our agent has knowledge of a change in or a violation of a policy condition, this will be considered our knowledge and will not void the policy or defeat a recovery for a claim. II. "Workers Compensation Law" means Chapter 102, Wisconsin Statutes. It does not include and this policy does not apply to any obligation under Chapter 40, Wisconsin Statutes, or Section 66.191, Wisconsin Statues, or any amendment to these laws. III. Any language involving "Actions Against Us" is replaced and amended to provide that no legal action may be brought against us until there has been full compliance with all the terms of this policy. IV. Any language involving "Recovery From Others" is amended to provide that we are entitled to recover our payments under this policy from anyone liable for the covered injury, but only if you and the person entitled to benefits under this insurance have been fully compensated. V. If an injury occurs that may be covered by this insurance, the policy is amended to provide that you must notify us of the injury as soon as reasonably possible. VI. The CANCELATION Condition of the policy, as respects coverage provided in Wisconsin, is replaced by the following provisions. A. CANCELATION 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancelation is to take effect. 2. We may cancel the policy for any reason if the policy has been in effect for less than sixty (60) days. If the policy is issued for a term longer than one year or for an indefinite term, we may cancel the the policy for any reason on an annual anniversary of the policy effective date. We may cancel the policy at any other time for the following reasons: a. you fail to pay all premium when due; b. a material misrepresentation; c. a substantial breach of the obligations, conditions or warranties under the policy; or d. a substantial change in the risk we assumed under the policy unless it was reasonable for us to forsee the change or expect the risk when we issued the policy. WC 48 06 01 B (ED. 04-94) -1- INSURED'S COPY 3. If we cancel for nonpayment of premium when due, or any other permissible reason, we must deliver or mail, first class, not less than thirty (30) days advance written notice stating when the cancelation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 4. The policy period will end on the day and hour stated in a notice of cancelation. B. NONRENEWAL 1. You have the right to have the insurance renewed unless we deliver or mail to you not less than sixty (60) days advance written notice stating our intention not to renew this policy. 2. We do not have to renew the insurance if you do not pay the renewal premium billing by the due date or if you accept replacement insurance, are insured elsewhere, request or agree to nonrenewal, or if the policy is expressly designated as being nonrenewable. 3. If we renew the insurance, we may use the policy forms, rates and rating plans we are then using for similar risks. We may limit the policy to a term equivalent to the term of the expiring policy or one year, whichever is less. 4. If we renew or offer to renew the insurance on terms or rates less favorable to you than the expiring policy, you have sixty (60) days after you receive notice of the changes to cancel. Premium will be calculated using the new rates if you cancel because of a general rate increase. Premium will be calculated using the old rates if you cancel because of a general rate increase. Premium will be calculated using the old rates if you cancel for any other reason. This does not apply to an increase in rates because of an increase in risk that results in a changed classification under the manual we are using then. WC 48 06 01 B COUNTERSIGNED BY ________________________________ (ED. 04-94) AUTHORIZED REPRESENTATIVE -2- INSURED'S COPY PAGE 00 1 ENDORSEMENT # 0000 1 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-43 Issued to: OUTSOURCE INTERNATIONAL, INC. By: NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. NAMED INSUREDS FEIN -------------- ---- 00001 OUTSOURCE INTERNATIONAL, INC. 592754571 00002 SYNADYNE I 592754571 (DBA) PAYROLL PARTNERS 00003 LABOR WORLD OF AMERICA, INC. 592754571 (DBA) SYNADYNE III 00004 OUTSOURCE FRANCHISING, INC. 592754571 00005 SYNADYNE II 650021598 (DBA) PAYROLL PARTNERS 00006 SYNADYNE IV 650021598 00007 SYNADYNE V 650021598 00008 CAPITAL STAFFING FUND, INC. 592754571 00009 SMSB ASSOCIATES, INC. 592754571 ---------------------------------- AUTHORIZED REPRESENTATIVE Issue Date; 04/01/97 lwO003 INSURED'S COPY PAGE 001 ENDORSEMENT # 00002 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-43 Issued to: OUTSOURCE INTERNATIONAL, INC. By: NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. ADDITIONAL LOCATIONS -------------------- 00001 8000 NORTH FEDERAL HIGHWAY BOCA RATON FL 33487 00002 2033 LATHROP AVENUE RACINE WI 53405 00003 322 E. BAY STREET MILWAUKEE WI 59207 00004 JOB SITE ONLY SALT LAKE CITY UT 84101 00005 2033 LATHROP AVENUE RACINE WI 53405 00006 2033 LATHROP AVENUE RACINE WI 53405 00007 2033 LATHROP AVENUE RACINE WI 53405 00008 2033 LATHROP AVENUE RACINE WI 53405 00009 2033 LATHROP AVENUE RACINE WI 53405 00010 2033 LATHROP AVENUE RACINE WI 53405 ------------------------------------ AUTHORIZED REPRESENTATIVE Issue Date: 04/01/97 lwO004 INSURED'S COPY PAGE 002 ENDORSEMENT # 00002 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-43 Issued to: OUTSOURCE INTERNATIONAL, INC. By: NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. ADDITIONAL LOCATIONS -------------------- 00011 2033 LATHROP AVENUE RACINE WI 53405 ----------------------------------- AUTHORIZED REPRESENTATIVE Issue Date: 04/01/97 lwO004 INSURED'S COPY ENDORSEMENT # 00003 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-43 Issued to: OUTSOURCE INTERNATIONAL, INC. By: NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. NOTICE OF CANCELLATION PART SIX, PARAGRAPH D.2. OF THE WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY IS REPLACED BY THE FOLLOWING: WE MAY CANCEL THIS POLICY. WE MUST MAIL OR DELIVER TO YOU NOT LESS THAN NINETY (90) DAYS ADVANCE WRITTEN NOTICE, TEN (10) DAYS FOR NON-PAYMENT OF PREMIUM STATING WHEN THE CANCELLATION IS TO TAKE EFFECT. MAILING THAT NOTICE TO YOU AT YOUR MAILING ADDRESS SHOWN IN ITEM 1 OF THE INFORMATION PAGE WILL BE SUFFICIENT TO PROVE NOTICE. ----------------------------------- AUTHORIZED REPRESENTATIVE Issue Date: 04/01/97 lwO014 INSURED'S COPY ENDORSEMENT This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-43 Issued to: OUTSOURCE INTERNATIONAL, INC. By: NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. THIS POLICY PROVIDES NO COVERAGE IN THE STATE OF MAINE. ------------------------------------ AUTHORIZED REPRESENTATIVE Issue Date: 04/01/97 WC880001 INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-44 ARIZONA - ------------------ -------- ------------------------------ POLICY PREFIX & No. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ---------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ---------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS SPECIFICALLY CODE ESTIMATED TOTAL PER $100 OF ESTIMATED PROVIDED ELSEWHERE IN THIS POLICY, DO NOT MODIFY NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS ANY OF THE OTHER PROVISIONS OF THIS POLICY. CONSTRUCTION OF PRIVATE RESIDENCE FENCE ERECTION - WOOD NOC 5403 88,500 24.24 21,452 CARPENTRY - INSTALLATION OF FINISHED 5437 400 8.13 33 WOODEN FLOORING WATERPROOFING -ROOFS OF MOBILE 5474D 4,300 13.28 571 HOMES & DRIVERS. AIR CONDITIONING SYSTEMS - REFRIGERATED 5537 1,200 9.64 116 AND EVAPORATED AIR CONDITIONING SHOP AND OUTSIDE AND DRIVERS CLEANER - DEBRIS REMOVAL 5610 102,600 7.55 7,746 GRADING OF LAND NOC & DRIVERS 6217 200 9.83 20 F___ SUNDRIES MFG.N 0 C -NO CEREAL 6504 27,200 4.26 1,159 MILLING AUTOMOBILE RENTAL CO: ALL OTHER 7382 2,000 8.00 160 EMPLOYEES & DRIVERS ELECTRIC LIGHT OR POWER COMPANY-NOC-ALL 7539 300 2.96 9 EMPLOYEES-& DRIVERS BURGLAR ALARM INSTALLATION OR REPAIR 7605 1,200 3.47 42 & DRIVERS AUTOM0BILE RENTAL CO: 8002 500 2.87 14 ALL OTHER EMPLOYEES & COUNTER PERSONNEL,DRIVERS STORE: HARDWARE 8010 4,700 2.51 118 CLUB SHOOTING 8017 96,900 2.33 2,258 STORE GROCERY WHOLESALE 8018 40,000 4.93 1,972 FURNITURE STORES --WHOLESALE OR RETAIL 8044 40,300 3.13 1,261 & DRIVERS MOBILE ACCESSORY STORES RETAIL- 8046 5,600 2.58 144 _____& DRIVERS - ---------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-44 ARIZONA - ------------------ -------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------- INTRA/INDEPENDENT STATE RISK ID - --------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - --------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS SPECIFICALLY CODE ESTIMATED TOTAL PER $100 OF ESTIMATED PROVIDED ELSEWHERE IN THIS POLICY, DO NOT MODIFY NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS ANY OF THE OTHER PROVISIONS OF THIS POLICY. STORE: DRUG - WHOLESALE 8047 2,300 3.72 86 STORE: FIVE AND TEN CENT 8050 300 1.44 4 BUILDING MATERIAL DEALER - NEW MATERIALS 8058 9,600 4.10 394 ONLY: STORE EMPLOYEES METAL MERCHANT & DRIVERS 8106 3,000 10.28 308 APPLIES TO DEALERS OF IRON, STEEL OR NONFERROUS METAL. PLUMBERS' SUPPLIES DEALER & DRIVERS NPD 8111 2,200 3.46 76 CONTRACTOR'S PERMANENT YARD 8227D 200 8.77 18 ____DEALER NPD 8263 1,700 8.68 148 STORAGE WAREHOUSE - COLD 8291 4,800 7.12 342 STORAGE WAREHOUSE NOC 8292 140,600 5.94 8,352 STORAGE WAREHOUSE - FURNITURE & 8293 18,800 12.00 2,256 DRIVERS AUTOMOBILE CAR WASH AND DRIVERS 8380 13,300 4.38 583 AUTOMOBILE RENTAL CO.GARAGE EMPLOYEES 8385 12,700 4.70 597 SALESPERSONS, COLLECTORS OR MESSENGERS 8742 76,400 0.66 504 OUTSIDE LETTER SERVICE SHOP & CLERICAL NPD 8800 100 3.08 3 CLERICAL OFFICE EMPLOYEES NOC 8810 585,500 0.47 2,752 TELEPHONE OR TELEGRAPH CO: OFFICE OR 8901 100 0.52 1 EXCHANGE EMPLOYEES & CLERICAL MOBILE POWER CLEANING SERVICE -NOC- BY 9014D 29,600 5.95 1,761 CONTRACTOR ___EMENT PARK OR EXHIBITION 9016 900 4.58 41 OPERATION & DRIVERS - -------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-44 ARIZONA - ------------------- -------- -------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID -------------------------------- INTRA/INDEPENDENT STATE RISK ID - --------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - --------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS SPECIFICALLY CODE ESTIMATED TOTAL PER $100 OF ESTIMATED PROVIDED ELSEWHERE IN THIS POLICY, DO NOT MODIFY NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS ANY OF THE OTHER PROVISIONS OF THIS POLICY. HOTEL: ALL OTHER EMPLOYEES & 9052D 200 4.06 8 SALESPERSONS, DRIVERS HOTEL: RESTAURANT EMPLOYEES 9058D 200 3.07 6 LAWN MAINTENANCE - COMMERCIAL OR 9102 1,000 7.02 70 DOMESTIC & DRIVERS CODES 9102 AND 0042, LANDSCAPE GARDENING AND DRIVERS MAY BE ASSIGNED TO THE SAME RISK. THE PAYROLL OF AN INDIVIDUAL EMPLOYEE MAY BE DIVIDED AND ALLOCATED BETWEEN CODES 0042 AND 9102 PROVIDED THAT THE ENTRIES ON THE ORIGINAL RECORDS OF THE INSURED DISCLOSE AN ALLOCATION OF EACH INDIVIDUAL'S PAYROLL. AN ESTIMATE OR PERCENTAGE ALLOCATION OF PAYROLL IS PERMITTED. ASHES, GARBAGE OR REFUSE COLLECTION & DRIVERS 9403 124,700 14.10 17,583 PAINTING: SHOP ONLY & DRIVERS NPD 9501D 1,500 3.44 52 UNMODIFIED PREMIUM 136,663 INCREASED LIMITS-EMPLOYER LIABILITY 2% 9812 2,733 LOSS REIMBURSEMENT $250,000 9962 (8,289) T0TAL UNMODIFIED PREMIUM 131,107 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 (27,532) SCHEDULE MODIFICATION 25% 9887 (25,894) MODIFIED STANDARD PREMIUM 77,681 - --------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-44 ARIZONA - ------------------- -------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ---------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ---------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS SPECIFICALLY CODE ESTIMATED TOTAL PER $100 OF ESTIMATED PROVIDED ELSEWHERE IN THIS POLICY, DO NOT MODIFY NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS ANY OF THE OTHER PROVISIONS OF THIS POLICY. UNDISCOUNTED PREMIUM 77,681 TOTAL ESTIMATED ANNUAL PREMIUM 77,681 TOTAL DUE 77,681 - ---------------------------------------------------------------------------------------------------------------------- WC 7754(Ed.4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-44 MARYLAND --------------------- ------------ ------------------------------- Policy Prefix & No. Schedule State Employer/Unemployment ID ------------------------------- Intra/Independent State Risk ID - ------------------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------------- Entries in this item, except as specifically Code Estimated Total Per $100 of Estimated provided elsewhere in this policy, do not modify No. Annual Remuneration Remuneration Annual Premiums any of the other provisions of this policy. SYNADYNE I JOB SITE ONLY REDLAND, MD 20855 CLERICAL OFFICE EMPLOYEES NOC 8810 818,500 0.32 2,619 LABOR WORLD OF AMERICA, INC. JOB SITE ONLY BALTIMORE, MD 21201 CARPENTRY - INSTALLATION OF FINISHED 5437 600 6.80 41 WOODEN FLOORING [ILLEGIBLE] CEILING OR WALL COVERING 5538 13,500 8.05 1,087 INSTALLATION & SHOP, DRIVERS TIMEKEEPERS-CONSTRUCTION OR ERECTION 5610 211,300 6.28 13,270 CARPENTRY-DWELLINGS-THREE STORIES 5651 200 8.38 17 OR LESS FOOD SUNDRIES MFG.N 0 C -NO CEREAL 6504 23,300 3.32 774 MILLING CHAUFFEURS & HELPERS NOC COMMERCIAL 7380 40,300 6.34 2,555 GARBAGE WORKS 7590 13,900 5.72 795 STORE: HARDWARE 8010 5,300 1.76 93 STORE: RETAIL NOC 8017 180,000 1.95 3,510 STORE GROCERY WHOLESALE 8018 36,100 5.50 1,986 FURNITURE STORES --WHOLESALE OR RETAIL - 8044 5,900 3.32 196 & DRIVERS BUILDING MATERIAL DEALER - NEW MATERIALS 8232 22,800 4.66 1,062 [ILLEGIBLE] [ILLEGIBLE]OTHER EMPLOYEES & YARD, WAREHOUSE, WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-44 MARYLAND --------------------- ------------ ------------------------------- Policy Prefix & No. Schedule State Employer/Unemployment ID ------------------------------- Intra/Independent State Risk ID - ------------------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------------- Entries in this item, except as specifically Code Estimated Total Per $100 of Estimated provided elsewhere in this policy, do not modify No. Annual Remuneration Remuneration Annual Premiums any of the other provisions of this policy. DRIVERS RUBBER STOCK DEALER - USED - AND 8264 186,700 8.18 15,272 DRIVERS NPD STORAGE WAREHOUSE NOC 8292 13,600 6.06 824 STORAGE WAREHOUSE - FURNITURE - 8293 1,500 9.22 138 DRIVERS OIL OR GASOLINE DEALER & DRIVERS 8350 2,500 6.18 155 ARCHITECT OR ENGINEER - CONSULTING NPD 8601 1,500 1.10 17 SALESPERSONS, COLLECTORS OR MESSENGERS - 8742 92,800 0.61 566 OUTSIDE -ICAL OFFICE EMPLOYEES NOC 8810 386,700 0.32 1,237 BUILDINGS-OPERATION BY CONTRACTORS 9014 20,100 3.52 708 BUILDINGS NOC-OPERATION BY OWNER OR 9015 4,200 3.78 159 LESSEE AMUSEMENT PARK OR EXHIBITION 9016 19,600 3.17 621 OPERATION & DRIVERS HOTEL: RESTAURANT EMPLOYEES 9058 31,100 2.02 628 RESTAURANT NOC 9082 13,300 2.68 356 CARPET INSTALLATION 9521 8,300 4.79 398 UNMODIFIED PREMIUM 49,084 INCREASED LIMITS-EMPLOYER LIABILITY 3.3% 9812 1,620 TOTAL UNMODIFIED PREMIUM 50,704 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 - 10,648 MODIFIED STANDARD PREMIUM 40,056 WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-44 MARYLAND - --------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. LOSS REIMBURSEMENT $250,000 9862 - 22,245 UNDISCOUNTED PREMIUM 17,811 TOTAL ESTIMATED ANNUAL PREMIUM 17,811 TOTAL DUE 17,811 - ------------------------------------------------------------------------------------------------------------------------ WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-44 VIRGINIA - --------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. SYNADINE I JOB SITE ONLY BEL AIR, VA 22042 CLERICAL OFFICE EMPLOYEES NOC 8810 193,800 0.19 368 LABOR WORLD OF AMERICA, INC. JOB SITE ONLY SPRINGSFIELD, VA 22150 FARM: NURSERY EMPLOYEES & DRIVERS 0005 50 2.85 1 INCLUDES INCIDENTAL LANDSCAPING GARDENING ________ DAIRY & DRIVERS 0036 300 6.25 19 LANDSCAPE GARDENING & DRIVERS 0042 8,500 6.09 518 CODES 0042 AND 9102 PARK NOC MAY BE ASSIGNED TO THE SAME RISK. THE PAYROLL OF AN INDIVIDUAL EMPLOYEE MAY BE DIVIDED AND ALLOCATED BETWEEN CODES 0042 AND 9102 PROVIDED THAT THE ENTRIES ON THE ORIGINAL RECORDS OF THE INSURED DISCLOSE AN ALLOCATION OF EACH INDIVIDUAL'S PAYROLL. AN ESTIMATE OR PERCENTAGE ALLOCATION OF PAYROLL IS NOT PERMITTED. HAY BALING & DRIVERS 0050 1,400 3.67 51 BOTTLING - NOT CARBONATED LIQUIDS OR 2156 1,800 6.39 115 SPIRITUOUS LIQUORS - & ROUTE SUPERVISORS, DRIVERS NPD BOTTLING NOC & ROUTE SUPERVISORS, 2157 300 4.73 14 DRIVERS EMBROIDERY MFG. 2388 300 1.63 5 CARPET OR RUG MFG NOC 2402 3,000 2.10 63 ______ OR TENT MFG - SHOP 2576 6,700 2.25 151 - ------------------------------------------------------------------------------------------------------------------------ WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-44 VIRGINIA - --------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. CARPENTRY SHOP ONLY AND DRIVERS 2802 100 4.18 4 FURNITURE ASSEMBLING-WOOD-FROM 2881 300 1.87 6 MANUFACTURED PARTS SHEET METAL WORK - SHOP 3066 3,000 3.08 92 BUTTON OR FASTENER MFG-METAL 3131 3,000 1.63 49 ELECTRICAL APPARATUS MFG NOC 3179 4,600 1.74 80 ELECTRIC OR GAS LIGHTING FIXTURES MFG. 3180 600 1.77 11 MACHINE SHOP NOC 3632 1,031 2.73 28 ELECTRICAL APPARATUS INSTALLATION OR 3724 100 5.55 6 ________ & DRIVERS CLAY OR SHALE DIGGING & DRIVERS 4000 900 4.37 39 CONCRETE PRODUCTS MFG & DRIVERS 4034 1,500 5.65 85 PLASTERING OR STUCCO WORK-ON OUTSIDE OF 5022 300 8.10 24 BUILDINGS FURNITURE OR FIXTURES INSTALLATION - 5146 10,500 4.21 442 PORTABLE - NOC PLUMBING NOC & DRIVERS 5183 6,200 4.68 290 ELECTRICAL WIRING - WITHIN BUILDINGS 5190 200 3.52 7 & DRIVERS. COMPUTER DEVICE INSTALLATION 5191 79,100 0.67 530 INSPECTION SERVICE OR REPAIR INCLUDES SHOP OPERATIONS. COMPUTER MFG. TO BE SEPARATELY RATED. CONCRETE WORK-INCIDENTAL TO THE 5215 900 7.19 65 CONSTRUCTION OF PRIVATE RESIDENCE CONCRETE CEMENT WORK - FLOORS, 5221 1,700 4.90 83 ROADWAYS, YARDS OR SIDEWALKS - & - ------------------------------------------------------------------------------------------------------------------------ WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-44 VIRGINIA - --------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. DRIVERS SWIMMING POOL CONSTRUCTION - NOT IRON OR 5223 2,000 4.85 97 STEEL - & DRIVERS MARBLE OR STONE SETTING - INSIDE 5348 18,100 3.98 720 CARPENTRY NOC 5403 198,500 7.91 15,701 PLASTERING NOC & DRIVERS 5480 200 7.36 15 STREET OR ROAD CONSTRUCTION OR 5506 1,300 6.84 89 RECONSTRUCTION & DRIVERS FILLING OR GRADING TUNNELING BRIDGE OR CULVERT BUILDING QUARRYING STONE CRUSHING TO BE SEPARATELY RATED FILLING OR GRADING TUNNELING BRIDGE OR COVERT BUILDING QUARRYING STONE ____HING TO BE SEPARATELY RATED METAL CEILING OR WALL COVERING 5538 500 6.27 31 INSTALLATION & SHOP, DRIVERS CLEANER - DEBRIS REMOVAL 5610 403,400 6.39 25,777 CARPENTRY - DETACHED ONE OR TWO FAMILY 5645 102,700 8.98 9,222 DWELLINGS CARPENTRY-DWELLINGS-THREE STORIES 5651 8,600 8.79 756 OR LESS SALVAGE OPERATION - NO WRECKING OR ANY 5705 1,200 1.00 12 STRUCTURAL OPERATIONS FOOD SUNDRIES MFG.N 0 C -NO CEREAL 6504 24,600 2.44 600 MILLING TRUCKMEN: PARCEL OR PACKAGE DELIVERY - 7230 500 4.07 20 ALL EMPLOYEES & SALESMEN, DRIVERS FREIGHT HANDLING NOC COVERAGE UNDER 7350F 9,900 10.37 1,027 U. S. ACT REFRIGERATOR CAR LOADING OR UNLOADING 7360 62,100 4.38 2,720 - ------------------------------------------------------------------------------------------------------------------------ WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-44 VIRGINIA - --------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. CHAUFFEURS & HELPERS NOC COMMERCIAL 7380 3,000 3.51 105 ALE OR BEER DEALER - WHOLESALE - & 7390 600 4.24 24 DRIVERS GARBAGE WORKS 7590 80,000 4.46 3,568 FLORIST-STORE-DRIVERS 8001 200 1.24 2 STORE: COFFEE, TEA OR SPICE - RETAIL 8006 200 2.66 5 STORE: SHOE - RETAIL 8008 24,100 0.78 188 STORE: HARDWARE 8010 11,700 1.23 144 STORE: RETAIL NOC 8017 46,500 1.17 544 STORE GROCERY WHOLESALE 8018 4,700 2.31 109 STORE-MEAT, GROCERY AND PROVISION 8033 2,300 2.62 60 COMBINED RETAIL NOC STORE: DEPARTMENT - RETAIL - & SALESMEN 8039 3,000 1.53 46 CLERICAL FURNITURE STORES --WHOLESALE OR RETAIL - 8044 7,300 2.17 158 & DRIVERS AUTOMOBILE ACCESSORY STORE - RETAIL - 8046 300 1.63 5 NOC & SALESMEN, DRIVERS BUILDING MATERIAL DEALER - NEW MATERIALS 8058 5,800 2.15 125 ONLY: STORE EMPLOYEES STORE: GROCERY-CONVENIENCE-RETAIL 8061 900 2.84 26 BUILDING MATERIAL DEALER - NEW MATERIALS 8232 11,500 3.64 419 ONLY: ALL OTHER EMPLOYEES & YARD, WAREHOUSE, DRIVERS ______ DEALER NPD 8263 48,600 5.86 2,848 - ------------------------------------------------------------------------------------------------------------------------ WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-44 VIRGINIA - --------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. RUBBER STOCK DEALER - USED - AND 8264 600 8.75 53 DRIVERS NPD STORAGE WAREHOUSE NOC 8292 38,000 3.03 1,151 STORAGE WAREHOUSE - FURNITURE - & 8293 10,100 5.20 525 DRIVERS GASOLINE STATION RETAIL SELF SERVICE 8381 150 2.02 3 AUTOMOBILE STORAGE GARAGE OR PARKING 8392 3,800 1.49 57 STATION & DRIVERS TRAILER BODY MFG.--NOT "HOME" TYPE: 8393 150 1.99 3 THE AUTOMOBILE BODY CLASSIFICATION CONTEMPLATE THE COMPLETE MANUFACTURE AND ASSEMBLY OF TRAILERS, INCLUDING CHASSIS, BODY AND INSTALLATION OF INTERIOR EQUIPMENT. LETTER SERVICE SHOP & CLERICAL NPD 8800 300 1.84 6 CLERICAL OFFICE EMPLOYEES NOC 8810 269,300 0.19 512 BUILDINGS-OPERATION BY CONTRACTORS 9014 38,900 2.33 906 BUILDINGS NOC-OPERATION BY OWNER OR 9015 11,200 2.47 277 LESSEE AMUSEMENT PARK OR EXHIBITION 9016 300 1.71 5 OPERATION & DRIVERS HOSPITAL: ALL OTHER EMPLOYEES 9040 9,300 2.08 193 HOTEL - ALL EMPLOYEES & SALESPERSON & 9052 15,900 1.96 312 DRIVERS HOTEL: RESTAURANT EMPLOYEES 9058 300 1.68 5 RESTAURANT NOC 9082 7,800 1.71 133 ____LING LANE 9093 3,700 1.04 38 LAWN MAINTENANCE - COMMERCIAL OR 9102 3,000 2.08 84 - ------------------------------------------------------------------------------------------------------------------------ WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-44 VIRGINIA - --------------- --------------- ------------------------------- POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYER ID ------------------------------- INTRA/INDEPENDENT STATE RIKS ID - ------------------------------------------------------------------------------------------------------------------------ ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------ ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUM THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. DOMESTIC & DRIVERS CODES 9102 AND 0042, LANDSCAPE GARDENING AND DRIVERS MAY BE ASSIGNED TO THE SAME RISK. THE PAYROLL OF AN INDIVIDUAL EMPLOYEE MAY BE DIVIDED AND ALLOCATED BETWEEN CODES 0042 AND 9102 PROVIDED THAT THE ENTRIES ON THE ORIGINAL RECORDS OF THE INSURED DISCLOSE AN ALLOCATION OF EACH INDIVIDUAL'S PAYROLL. AN ESTIMATE OR PERCENTAGE ALLOCATION OF PAYROLL IS NOT PERMITTED. PAINTING: SHOP ONLY & DRIVERS NPD 9501 3,200 1.82 58 UNMODIFIED PREMIUM 72,631 INCREASED LIMITS-EMPLOYER LIABILITY 3.3% 9812 2,397 TOTAL UNMODIFIED PREMIUM 75,028 _________ MODIFICATION (TENTATIVE) .79 9898 - 15,756 _________ STANDARD PREMIUM 59,272 LOSS REIMBURSEMENT $250,000 9862 - 8,271 UNDISCOUNTED PREMIUM 51,001 EXPENSE CONSTANT 0900 160 TOTAL ESTIMATED ANNUAL PREMIUM 51,161 TOTAL DUE 51,161 - ------------------------------------------------------------------------------------------------------------------------ WC 7754 (Ed. 4-81) INSURED'S COPY LARGE RISK RATING PLAN ENDORSEMENT (SHORT FORM) This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-44 Issued to OUTSOURCE INTERNATIONAL, INC By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA The premium for this policy will be determined according to the Large Risk Rating Plan Endorsement attached to policy NO. RMWC 2177940 53820 COUNTERSIGNED BY _____________________________ (ED. 07-92) AUTHORIZED REPRESENTATIVE INSURED'S COPY DEFENSE BASE ACT COVERAGE ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-44 Issued to OUTSOURCE INTERNATIONAL, INC By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the work described in the Schedule or described on the Information Page as subject to the Defense Base Act. The policy applies to that work as though the location included in the description of the work were a state named in Item 3.A. of the Information Page. General Section C. WORKERS' COMPENSATION LAW is replaced by the following: C. WORKERS' COMPENSATION LAW Workers' Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page and the Defense Base Act (42 USC Sections 1651-1654). It includes any amendments to those laws that are in effect during the policy period. It does not include any other federal workers or workmen's compensation law, other federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. Part Two (Employers Liability Insurance), C. Exclusions., exclusion 8, does not apply to work subject to the Defense Base Act. Schedule DESCRIPTION OF WORK - ------------------- NO WORK AT THIS TIME. IT IS AGREED THAT IF ANY WORK IS SUBJECT TO THE DEFENSE BASE ACT, THE INSURER WILL ENDORSE THE POLICY WITHIN SIXTY (60) DAYS OF NOTIFICATION. WC 00 01 01 A COUNTERSIGNED BY _______________________________ (ED. 4-92) AUTHORIZED REPRESENTATIVE INSURED'S COPY LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-44 Issued to OUTSOURCE INTERNATIONAL, INC By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to work subject to the Longshore and Harbor Workers' Compensation Act in a state shown in the Schedule. The policy applies to that work as though that state were listed in Item 3.A. of the Information Page. General Section C. WORKERS' COMPENSATION LAW is replaced by the following: C. WORKERS' COMPENSATION LAW Workers' Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page and the Longshore and Harbor Workers' Compensation Act (33 USC Sections 901-950). It includes any amendments to those laws that are in effect during the policy period. It does not include any other federal workers or workmen's compensation law, other federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. Part Two (Employers Liability Insurance), C. Exclusions., exclusion 8, does not apply to work subject to the Longshore and Harbor Workers' Compensation Act. This endorsement does not apply to work subject to the Defense Base Act, the Outer Continental Shelf Lands Act, or the Nonappropriated Fund Instrumentalities Act. Schedule STATE LONGSHORE AND HARBOR WORKERS' - ----- COMPENSATION ACT COVERAGE PERCENTAGE ------------------------------------ ARIZONA 52.00 MARYLAND 10.00 VIRGINIA 72.00 The rates for classifications with code numbers not followed by the letter "F" are rates for work not ordinarily subject to the Longshore and Harbor Workers' Compensation Act. If this policy covers work under such classifications, and if the work is subject to the Longshore and Harbor Workers' Compensation Act, those non-F classification rates will be increased by the Longshore and Harbor Workers' Compensation Art Coverage Percentage shown in the Schedule. WC 00 01 06 A COUNTERSIGNED BY ___________________________ (ED. 4-92) AUTHORIZED REPRESENTATIVE INSURED'S COPY ALTERNATE EMPLOYER ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-44 Issued to OUTSOURCE INTERNATIONAL, INC By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only with respect to bodily injury to your employees while in the course of special or temporary employment by the alternate employer in the state named in Item 2 of the Schedule. Part One (Workers Compensation Insurance) and Part Two (Employers Liability Insurance) will apply as though the alternate employer is insured. If an entry is shown in Item 3 of the Schedule the insurance afforded by this endorsement applies only to work you perform under the contract or at the project named in the Schedule. Under Part One (Workers Compensation Insurance) we will reimburse the alternate employer for the benefits required by the workers compensation law if we are not permitted to pay the benefits directly to the persons entitled to them. The insurance afforded by this endorsement is not intended to satisfy the alternate employer's duty to secure its obligations under the workers compensation law. We will not file evidence of this insurance on behalf of the alternate employer with any government agency. We will not ask any other insurer of the alternate employer to share with us a loss covered by this endorsement. Premium will be charged for your employees while in the course of special or temporary employment by the alternate employer. The policy may be cancelled according to its terms without sending notice to the alternate employer. Part Four (Your Duties If Injury Occurs) applies to you, and the alternate employer. The alternate employer will recognize our right to defend under Parts One and Two and our right to inspect under Part Six. SCHEDULE 1. ALTERNATE EMPLOYER ADDRESS 2. STATE OF SPECIAL OR TEMPORARY EMPLOYMENT 3. CONTRACT OR PROJECT "ANY CLIENT IS INCLUDED AS AN ALTERNATE EMPLOYER AS RESPECTS THE USE OF TEMPORARY OR LEASED EMPLOYEES OF OUTSOURCE INTERNATIONAL AND AFFILIATED RELATED COMPANIES PER WRITTEN AGREEMENT BETWEEN THE PARTIES PRIOR TO LOSS." WC 00 03 01 A COUNTERSIGNED __________________________ (ED. 02-89) AUTHORIZED REPRESENTATIVE INSURED'S COPY VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-44 Issued to OUTSOURCE INTERNATIONAL, INC By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement adds Voluntary Compensation Insurance to the policy. A. HOW THIS INSURANCE APPLIES This insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must be sustained by an employee included in the group of employees described in the Schedule. 2. The bodily injury must arise out of and in the course of employment necessary or incidental to work in a state listed in the Schedule. 3. The bodily injury must occur in the United States of America, its territories or possessions, or Canada, and may occur elsewhere if the employee is a United States or Canadian citizen temporarily away from those places. 4. Bodily injury by accident must occur during the policy period. 5. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. B. WE WILL PAY We will pay an amount equal to the benefits that would be required of you if you and your employees described in the Schedule were subject to the workers compensation law shown in the Schedule. We will pay those amounts to the persons who would be entitled to them under the law. C. EXCLUSIONS This insurance does not cover: 1. any obligation imposed by a workers compensation or occupational disease law, or any similar law. 2. bodily injury intentionally caused or aggravated by you. D. BEFORE WE PAY Before we pay benefits to the persons entitled to them, they must: 1. Release you and us, in writing, of all responsibility for the injury or death. 2. Transfer to us their right to recover from others who may be responsible for the injury or death. 3. Cooperate with us and do everything necessary to enable us to enforce the right to recover from others. If the persons entitled to the benefits of this insurance fail to do those things, our duty to pay ends at once. If they claim damages from you or from us for the injury or death, our duty to pay ends at once. WC 00 03 11 A (ED. 8-91) Page 1 of 2 INSURED'S COPY PAGE 001 ENDORSEMENT # 00002 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-44 Issued to: OUTSOURCE INTERNATIONAL, INC By: THE INSURANCE COmPANY OF THE STATE OF PENNSYLVANIA ADDITIONAL LOCATIONS -------------------- 00001 8000 N FEDERAL HIGHWAY BOCA RATON FL 33487 00002 JOB SITE ONLY PHOENIX AZ 85016 00003 5343 NORTH 16TH ST., STE 33 PHOENIX AZ 85016 00004 JOB SITE ONLY BEL AIR VA 22042 00005 JOB SITE ONLY SPRINGSFIELD VA 22150 00006 JOB SITE ONLY REDLAND MD 20855 00007 JOB SITE ONLY BALTIMORE MD 21201 00008 JOB SITE ONLY PHOENIX AZ 85016 00009 JOB SITE ONLY PHOENIX AZ 85016 00010 JOB SITE ONLY PHOENIX AZ 85016 --------------------------- AUTHORIZED REPRESENTATIVE Issue Date: 04/14/97 IW0004 INSURED'S COPY PAGE 002 ENDORSEMENT # 00002 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-44 Issued to: OUTSOURCE INTERNATIONAL, INC By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA ADDITIONAL LOCATIONS -------------------- 00011 JOB SITE ONLY PHOENIX AZ 85016 00012 JOB SITE ONLY PHOENIX AZ 85O16 00013 JOB SITE ONLY PHOENIX AZ 85016 ----------------------------- AUTHORIZED REPRESENTATIVE Issue Date: 04/14/97 IW0004 INSURED'S COPY E. RECOVERY FROM OTHERS If we make a recovery from others, we will keep an amount equal to our expenses of recovery and the benefits we paid. We will pay the balance to the persons entitled to it. If the persons entitled to the benefits of this insurance make a recovery from others, they must reimburse us for the benefits we paid them. F. EMPLOYERS LIABILITY INSURANCE Part Two (Employers Liability Insurance) applies to bodily injury covered by this endorsement as though the State of employment shown in the Schedule were shown in Item 3.A of the Information Page. SCHEDULE DESIGNATED WORKERS EMPLOYEES STATE OF EMPLOYMENT COMPENSATION LAW - --------- ------------------- ---------------- ALL OFFICERS AND ALL STATES EXCEPT STATE OF HIRE EMPLOYEES NOT SUBJECT AL, IA, IN, KY, LA, MA TO THE WORKERS COMPENSATION MI, MN, M0, MS, NE, NH LAW EXCEPT MASTERS NM, NY, PA, SC, TN, TX OR MEMBERS OF THE CREW UT, WI, CA, ID, OR OF ANY VESSEL. This endorsement does not apply in New Jersey, Nevada, North Dakota, Ohio, Washington, Wisconsin, West Virginia, Wyoming, and Maine. WC 00 03 11 A COUNTERSIGNED BY _____________________________ (ED. 8-91) AUTHORIZED REPRESENTATIVE Page 2 of 2 INSURED'S COPY EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-44 Issued to OUTSOURCE INTERNATIONAL, INC BY THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA The premium for the policy will be adjusted by an experience rating modification factor. The factor was not available when the policy was issued. The factor, if any, shown on the Information Page is an estimate. We will issue an endorsement to show the proper factor, if different from the factor shown, when it is calculated. WC 00 04 03 COUNTERSIGNED BY __________________________ (ED. 4-84) AUTHORIZED REPRESENTATIVE INSURED'S COPY NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01AM 01/01/97 forms a part of Policy No. RM WC 217-79-44 Issued to OUTSOURCE INTERNATIONAL, INC By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA Experience rating is mandatory for all eligible insureds. The experience rating modification factor, if any, applicable to this policy, may change if there is a change in your ownership or in that of one or more of the entities eligible to be combined with you for experience rating purposes. Change in ownership includes sales, purchases, other transfers, mergers, consolidations, dissolutions, formations of a new entity and other changes provided for in the applicable experience rating plan manual. You must report any change in ownership to us in writing within 90 days of such change. Failure to report such changes within this period may result in revision of the experience rating modification factor used to determine your premium. THIS ENDORSEMENT IS NOT APPLICABLE IN NEW JERSEY, PENNSYLVANIA, MICHIGAN, ALASKA, CALIFORNIA, DELAWARE, MAINE OR TEXAS. WC 00 04 14 COUNTERSIGNED BY _____________________________ (ED. 7-90) AUTHORIZED REPRESENTATIVE INSURED'S COPY LOSS REIMBURSEMENT ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-44 Issued to OUTSOURCE INTERNATIONAL, INC By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA PLEASE READ IT CAREFULLY. This Endorsement applies solely between you and us. It does not affect the rights of others under this policy. I. Payment and Reimbursement Conditions a. We will pay the sum of: 1. all benefits payable under PART ONE - WORKERS COMPENSATION INSURANCE; and 2. up to our limit of liability, all sums you legally must pay as damages to which PART TWO - EMPLOYERS LIABILITY applies; and 3. all benefits payable under PART THREE - OTHER STATES INSURANCE; and 4. all benefits or damages payable under any endorsements attached to the policy. b. You will reimburse us promptly up to the reimbursement limit(s) shown in the Schedule for any amounts we have so paid. You agree further to reimburse us for any "allocated loss adjusting expense" we pay according to the election indicated by an "X" below. If we make no payment, you must reimburse us for all "allocated loss adjusting expense". If no election is indicated, election C applies. Your obligation to reimburse us for "allocated loss adjusting expense" applies separately to "each accident" or, for bodily injury by disease, to "each claim". A. All allocated loss adjusting expenses up to the amount by which the applicable "Each Accident" or "Each Claim" reimbursement limit exceeds the amount you must reimburse us for payments we make under Section 1. A. above. B. All allocated loss adjusting expenses. C. A part of all allocated loss adjusting expenses in the proportion that the sum you must reimburse us for payments we make under 1. A. above bears to all sums payable by us thereunder. c. If a Limit is shown in the Schedule as "Aggregate", that Limit is the most you must reimburse us for all benefits and all damages (but not "allocated loss adjustment expense") that we pay under this policy. The "aggregate" will not be reduced if this policy is issued for a term of less than one year, or if the policy or this endorsement is canceled before the end of the policy period. If no "Aggregate" Limit is shown in the Schedule, no aggregate limit applies to your reimbursement obligation. No limit on the Company's liability under the POLICY OR ANY endorsement is increased or reinstated by this endorsement or by any reimbursement to us under the terms of this endorsement. WC53138 (ED. 2-92) 1 of 3 LWNLOSS INSURED'S COPY II. General Conditions A. Duties a. The first Named Insured shown in the Information Page agrees and is authorized to reimburse us for any reimbursable amounts we pay on behalf of any Insureds. b. each Named Insured is jointly and severally liable for all reimbursable amounts under this policy. c. All other terms of the policy, including those which apply to (1) our right and duty to defend any claim, proceeding or suit against you, and (2) your duties if injury or disease occurs, apply without change on account of this endorsement. B. Cancellation of This Endorsement You must reimburse us for any amounts that we pay within the Reimbursement Limits, and for your share of the "Allocated Loss Adjustment Expense", within 15 days of your receipt of an invoice from us. You must deliver to us such instruments of financial security, or amendments thereto, as we may require, within 15 days of our demand therefor. If you fail to do either, we may cancel this endorsement by mailing or delivering written notice to you not less than 10 days prior to the effective date of such cancellation stating the day and hour the cancellation is to take effect. Proof of the mailing of such notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. If we cancel this endorsement, you must pay us within 15 days of our invoice an additional premium that we will specify, calculated according to our rates and rules as filed and approved by regulatory agencies having jurisdiction. C. Recovery From Others We have your rights and the rights of persons entitled to the benefits of this insurance to recover all payments, including those within your reimbursement limit, from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. If we recover any payment we made under this policy from anyone liable for the injury, the amount we recover will first be applied to any payments we made in excess of the reimbursement limit or in excess of the "aggregate", and to our expenses in obtaining the recovery. The remainder of the recovery, if any, will be applied to reduce the amount that is reimbursable by you. D. Premium A discount in the premium for this policy is shown in the Schedule(s), calculated in accordance with our rating plan as filed and approved by regulatory agencies having jurisdiction. In the event that after the effective date of this policy additional or increased taxes or assessments are imposed upon us, not included in the calculation of the estimated annual premium hereof, we will recalculate the premium to include such additional costs and will reduce the discount accordingly. You will pay us any additional premium thus calculated promptly upon notice. III. Definitions 1. "Allocated loss adjustment expense" means claim adjustment expense allocated by us directly to particular claims. Such expenses shall include, but not be limited to, attorneys' fees for claims in suit, court costs, and other specific items of expense such as fees for medical examinations, expert testimony, laboratory, x-ray and autopsy services, stenographic services, witnesses and summonses, and copies of documents. WC53138 (ED. 2-92) 2 of 3 LWNLOSS INSURED'S COPY 2. "Claim" means each demand you receive for: a. benefits required of you by the Workers' Compensation law, including a filing by your employee or by others legally entitled to do so on his or her behalf for such benefits with an agency authorized by law, and suit or other proceedings brought by your employee for such benefits or damages; or b. damages covered by this policy. SCHEDULE COVERAGE REIMBURSEMENT LIMITS Bodily Injury by Accident Each Accident Bodily Injury by Disease Each Claim All Covered Bodily Injury Aggregate STATES WC53138 COUNTERSIGNED BY _______________________________ (ED. 2-92) AUTHORIZED REPRESENTATIVE 3 of 3 LWNLOSS INSURED'S COPY ARIZONA CANCELLATION ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different, date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-44 Issued to OUTSOURCE INTERNATIONAL, INC By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by the policy because Arizona is shown in Item 3.A. of the Information Page. The Cancellation Condition of the policy is replaced by this Condition: D. CANCELLATION 1. You may cancel this policy. You must mail or deliver written notice to us stating when the cancellation is to take effect. 2. We may cancel this policy if you fail to pay premium when due. We must mail or deliver to you and the Industrial Commission of Arizona not less than 30 days advance written notice stating when the cancellation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 3. The policy will end on the day and hour stated in the cancellation notice. WC 02 06 01 COUNTERSIGNED BY __________________________ (ED. 5-86) AUTHORIZED REPRESENTATIVE INSURED'S COPY MARYLAND CANCELLATION ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-44 Issued to OUTSOURCE INTERNATIONAL, INC By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by the policy because Maryland is shown in Item 3.A. of the Information Page. The Cancellation Condition of the policy is replaced by this Condition: D. CANCELLATION 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancellation is to take effect. 2. We may cancel this policy. We will file with the Office of the Maryland Workmen's Compensation Commission, and mail by registered mail, not less than 30 days advance written notice stating when the cancellation is to take effect. Mailing this notice to you at your mailing address last known to us will be sufficient to prove notice. 3. The policy period will end on the day and hour stated in the cancellation notice. WC 19 06 01 COUNTERSIGNED BY _____________________________ (ED. 10-84) AUTHORIZED REPRESENTATIVE INSURED'S COPY VIRGINIA AMENDATORY ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-44 Issued to OUTSOURCE INTERNATIONAL, INC By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the Virginia insurance provided by the policy because Virginia is shown in item 3.A. of the Information Page. For Virginia insurance Part Six.D. (Conditions-Cancelation) is replaced By: 1. You may cancel this policy. You must mail or deliver advance written notice to us. You must provide written notice of your cancelation, including the date of and reasons for the cancelation, to the Workers Compensation Commission. 2. We may cancel this policy. We will provide you with 30 days notice of cancelation. We will provide the Workers Compensation Commission with immediate notice of such cancelation. This provision does not apply if you have obtained other insurance and that insurer has notified the Workers Compensation Commission that it is now providing your insurance. 3. In the event of cancelation by you or us, you must provide 30 days written notice of the cancelation to your covered employees. 4. We may not renew your policy. We will provide 30 days notice to you and to the Workers Compensation Commission of our decision to nonrenew. This provision does not apply if you have obtained other insurance and that insurer has notified the Workers Compensation Commission that it is now providing your insurance. 5. If you fail to pay the premium due on this policy we may cancel the policy by providing 10 days notice to you and to the Workers Compensation Commission. WC 45 06 02 COUNTERSIGNED BY __________________________ (ED. 07-93) AUTHORIZED REPRESENTATIVE INSURED'S COPY ENDORSEMENT This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RMWC 217-79-44 Issued to: OUTSOURCE INTERNATIONAL, INC By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA IMPORTANT NOTICE TO POLICY HOLDERS In the event you need to contact someone about this policy for any reason please contact your agent. If you have additional questions you may contact the insurance company issuing this policy at the following address and telephone number: INS CO OF THE STATE OF PENN Telephone 1-212-770-7000 If you have been unable to contact or obtain satisfaction from the company or the agent, you may contact the Virginia Bureau of Insurance at: Property and Casualty Division Bureau of Insurance P.O. Box 1157 Richmond, Virginia 23218 In state toll-free calls 1-800-552-7945 Out-of-state calls 1-804-371-9741 Written correspondence is preferable so that a record of your inquiry is maintained. When contacting your agent, company or the Bureau of Insurance, have your policy number available. -------------------------------- AUTHORIZED REPRESENTATIVE Issue Date: 04/14/97 LWNINPH INSURED'S COPY PAGE 001 ENDORSEMENT # 00001 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-44 Issued to: OUTSOURCE INTERNATIONAL, INC By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA NAMED INSUREDS FEIN -------------- ---- 00001 OUTSOURCE INTERNATIONAL, INC 592754571 00002 SYNADYNE I 592754571 (DBA) PAYROLL PARTNERS 00003 LABOR WORLD OF AMERICA, INC. 592754571 (DBA) SYNADYNE III 00004 OUTSOURCE FRANCHISING, INC. 592754571 00005 SYNADYNE II 650021598 (DBA) PAYROLL PARTNERS 00006 SYNADYNE IV 650021598 00007 SYNADYNE V 650021598 00008 CAPITAL STAFFING FUND, INC. 592754571 00009 SMSB ASSOCIATES, INC. 592754571 -------------------------------- AUTHORIZED REPRESENTATIVE Issue Date: 04/14/97 IWO003 ENDORSEMENT # 00003 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-44 Issued to: OUTSOURCE INTERNATIONAL, INC By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA NOTICE OF CANCELLATION PART SIX, PARAGRAPH D.2. OF THE WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY IS REPLACED BY THE FOLLOWING: WE MAY CANCEL THIS POLICY. WE MUST MAIL OR DELIVER TO YOU NOT LESS THAN NINETY (90) DAYS ADVANCE WRITTEN NOTICE, TEN (10) DAYS FOR NONPAYMENT OF PREMIUM STATING WHEN THE CANCELLATION IS TO TAKE EFFECT. MAILING THAT NOTICE TO YOU AT YOUR MAILING ADDRESS SHOWN IN ITEM 1 OF THE INFORMATION PAGE WILL BE SUFFICIENT TO PROVE NOTICE. -------------------------------- AUTHORIZED REPRESENTATIVE Issue Date: 04/14/97 IW0014 INSURED'S COPY ENDORSEMENT This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RMWC 217-79-44 Issued to: OUTSOURCE INTERNATIONAL, INC. By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA THIS POLICY PROVIDES NO COVERAGE IN THE STATE OF MAINE. ___________________________________ Authorized Representative Issue Date 04/14/97 WC880001 INSURED'S COPY ISSUED BY THE STOCK INSURANCE COMPANY HEREIN CALLED THE COMPANY AGENT NUMBER POLICY NUMBER THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA 13889 84324 RM WC 217-79-44 INCORPORATED UNDER THE LAWS OF PENNSYLVANIA ITEM 1. NAMED INSURED: MAILING ADDRESS IDENTIFICATION NO. OUTSOURCE INTERNATIONAL, INC. [LOGO] Member Companies of 8000 NORTH FEDERAL HIGHWAY American International Group BOCA RATON FL 33487-0000 EXECUTIVE OFFICES: 70 PINE STREET, NEW YORK, N.Y. 10270 I.D.# 917-356254 PRODUCERS NAME & MAILING ADDRESS WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CENTURY FINANCIAL SERVICES INFORMATION PAGE 185 N W SPANISH RIVER BLVD SUITE 170 BOCA RATON FL 33481 - -------------------------------------------------------------------------------- INSURED IS CORPORATION PREVIOUS POLICY NUMBER RMWC 2117626 - -------------------------------------------------------------------------------- OTHER WORKPLACES NOT SHOWN ABOVE - -------------------------------------------------------------------------------- ITEM 2 POLICY PERIOD 12:01 A.M. STANDARD TIME AT THE INSURED'S MAILING ADDRESS FROM 01/01/97 TO 01/01/98 - -------------------------------------------------------------------------------- ITEM 3 A. WORKERS COMPENSATION INSURANCE: PART ONE OF THE POLICY APPLIES TO WORKERS COMPENSATION LAW OF THE STATES LISTED HERE: AZ MD VA ------------------------------------------------------------------------- B. EMPLOYERS LIABILITY INSURANCE: PART TWO OF THE POLICY APPLIES TO THE WORK IN EACH STATE LISTED IN ITEM 3.A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE: BODILY INJURY BY ACCIDENT $1,000,000 EACH ACCIDENT BODILY INJURY BY DISEASE $1,000,000 POLICY LIMIT BODILY INJURY BY DISEASE $1,000,000 EACH EMPLOYEE ------------------------------------------------------------------------- C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO THE STATES, IF ANY, LISTED HERE: ALL STATES EXCEPT ME NV ND OH WA WV WY - -------------------------------------------------------------------------------- ITEM 4 THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, CLASSIFICATIONS, RATES AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. ------------------------------------------------------------------------- ESTIMATED TOTAL RATE PER ESTIMATED CLASSIFICATIONS CODE NUMBER REMUNERATION $100 OF RE- PREMIUM [X]ANNUAL [ ]3 YEAR NUMERATION [X]ANNUAL [ ]3 YEAR - -------------------------------------------------------------------------------- SEE ATTACHED SCHEDULES - -------------------------------------------------------------------------------- EXPENSE CONSTANT (EXCEPT WHERE APPLICABLE BY STATE) $160 VA - -------------------------------------------------------------------------------- MINIMUM PREMIUM $750 VA TOTAL ESTIMATED PREMIUM $146,653 - -------------------------------------------------------------------------------- Indicated below, interim adjustments of premium shall be made: [ ]Semi-Annually [ ]Quarterly [ ]Monthly DEPOSIT PREMIUM $ 146,653 - -------------------------------------------------------------------------------- ENDORSEMENTS (FORM NUMBER) SEE ATTACHED SCHEDULE - -------------------------------------------------------------------------------- 04/14/97 ATLANTA 07 - ------------------------------------------------- ISSUE DATE PRINT DATE: 04/15/97 ISSUING OFFICE ---------------------------------------- 39967 AUTHORIZED REPRESENTATIVE WC 00 00 01 INSURED'S COPY FORMS SCHEDULE Policy Number: RM WC 217-79-44 Effective Date: 01/01/97 - -------------------------------------------------------------------------------- WC000000A TERMS & CONDITIONS 53820 LARGE RISK RATING PLAN ENDT WC000101A DEFENSE BASE ACT COVERAGE ENDT WC000106A USL&H WC ACT COVERAGE END. WC000301A ALTERNATE EMPLOYER ENDORSEMENT WC000311A VOL COMP & EL COVERAGE ENDT WC000403 EXPERIENCE RATING MOD FACTOR WC000414 NOTIFICATION OF CHG OWNERSHIP WC53138 LOSS REIMBURSEMENT ENDORSEMENT WC020601 ARIZONA CANCELLATION WC190601 MD-CANCELLATION WC450602 VA AMENDATORY ENDORSEMENT LWNINPH VA NOTICE TO POLICYHOLDERS WC880001 ST OF ME EXCL LW0418 (ED. 1-92 INSURED'S COPY WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY National Union Fire Insurance Company of Pittsburgh, Pa. [LOGO] American Home Assurance Company Member Companies of American International Group, Inc. The Insurance Company of EXECUTIVE OFFICES The State of Pennsylvania 70 PINE STREET NEW YORK, N.Y. 10270 Birmingham Fire Insurance Company of Pennsylvania Commerce and Industry Insurance Company Coverage is provided by the Company designated on the Information Page A Stock Insurance Company WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY QUICK REFERENCE BEGINNING ON PAGE Information Page..........................................................i GENERAL SECTION...........................................................1 A. The Policy........................................................1 B. Who Is Insured....................................................1 C. Workers Compensation Law..........................................1 D. State.............................................................1 E. Locations.........................................................1 PART ONE-WORKERS COMPENSATION INSURANCE...................................1 A. How This Insurance Applies........................................1 B. We Will Pay.......................................................1 C. We Will Defend....................................................1 D. We Will Also Pay..................................................1 E. Other Insurance...................................................2 F. Payments You Must Make............................................2 G. Recovery From Others..............................................2 H. Statutory Provisions..............................................2 THESE POLICY PROVISIONS WITH THE INFORMATION PAGE AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THIS POLICY. "INCLUDES COPYRIGHT MATERIAL OF THE NATIONAL COUNCIL ON COMPENSATION INSURANCE, USED WITH ITS PERMISSION. COPYRIGHT 1983 NATIONAL COUNCIL ON COMPENSATION INSURANCE" 39638C(04/92) WC 00 00 00 A (STANDARD) INSURED'S COPY ED 4 O2 QUICK REFERENCE - CONTINUED BEGINNING ON PAGE PART TWO - EMPLOYERS LIABILITY INSURANCE .............................. 2 A- How This Insurance Applies ................................ 2 B. We Will Pay ............................................... 3 C. Exclusions ................................................ 3 D. We Will Defend ............................................ 3 E. We Will Also Pay .......................................... 4 F. Other Insurance ........................................... 4 G. Limits of Liability ....................................... 4 H. Recovery From Others ...................................... 4 I. Action Against Us ......................................... 4 PART THREE - OTHER STATES INSURANCE ................................... 4 A- How This Insurance Applies ................................ 4 B. Notice .................................................... 5 PART FOUR - YOUR DUTIES IF INJURY OCCURS .............................. 5 PART FIVE - PREMIUM ................................................... 5 A- Our Manuals ............................................... 5 B. Classifications ........................................... 5 C. Remuneration .............................................. 5 D. Premium Payments .......................................... 5 E. Final Premium ............................................. 5 F. Records ................................................... 6 G. Audit ..................................................... 6 PART SIX - CONDITIONS ................................................. 6 A- Inspection ................................................ 6 B. Long Term Policy .......................................... 6 C. Transfer of Your Rights and Duties ........................ 5 D. Cancellation .............................................. 6 E. Sole Representative ....................................... 6 IMPORTANT: This Quick Reference is not part of the Workers Compensation and Employers Liability Policy and does NOT provide coverage. Refer to the Workers Compensation and Employers Liability Policy itself for actual contractual provisions. PLEASE READ THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CAREFULLY INSURED'S COPY ATTACH FORM AND ENDORSEMENTS (IF ANY) HERE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows. GENERAL SECTION A. THE POLICY This policy includes at its effective date the Information Page and all endorsements and schedules listed there. It is a contract of insurance between you (the employer named in Item 1 of the Information Page) and us (the insurer named on the Information Page). The only agreements relating to this insurance are stated in this policy. The terms of this policy may not be changed or waived except by endorsement issued by us to be part of this policy. B. WHO IS INSURED You are insured if you are an employer named in Item 1 of the Information Page. If that employer is a partnership, and if you are one of its partners, you are insured, but only in your capacity as an employer of the partnership's employees. C. WORKERS COMPENSATION LAW Workers Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page. It includes any amendments to that law which are in effect during the policy period. It does not include any federal workers or workmen's compensation law, any federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. D. STATE State means any state of the United States of America, and the District of Columbia. E. LOCATIONS This policy covers all of your workplaces listed in Items 1 or 4 of the Information Page; and it covers all other workplaces in Item 3.A states unless you have other insurance or are self-insured for such workplaces. PART ONE - WORKERS COMPENSATION INSURANCE A. HOW THIS INSURANCE APPLIES This workers compensation insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. Bodily injury by accident must occur during the policy period. 2. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. B. WE WILL PAY We will pay promptly when due the benefits required of you by the workers compensation law. C. WE WILL DEFEND We have the right and duty to defend at our expense any claim, proceeding or suit against you for benefits payable by this insurance. We have the right to investigate and settle these claims, proceedings or suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. D. WE WILL ALSO PAY We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding or suit we defend: 1. reasonable expenses incurred at our request, but not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amount payable under this insurance; WC 00 00 00 A 1 of 7 INSURED'S COPY 3. litigation costs taxed against you; 4. interest on a judgment as required by law until we offer the amount due under this insurance; and 5. expenses we incur. E. OTHER INSURANCE We will not pay more than our share of benefits and costs covered by this insurance and other insurance or self-insurance. Subject to any limits of liability that may apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance will be equal until the loss is paid. F. PAYMENTS YOU MUST MAKE You are responsible for any payments in excess of the benefits regularly provided by the workers compensation law including those required because: 1. of your serious and willful misconduct; 2. you knowingly employ an employee in violation of law; 3. you fail to comply with a health or safety law or regulation; or 4. you discharge, coerce or otherwise discriminate against any employee in violation of the workers compensation law. If we make any payments in excess of the benefits regularly provided by the workers compensation law on your behalf, you will reimburse us promptly. G. RECOVERY FROM OTHERS We have your rights, and the rights of persons entitled to the benefits of this insurance, to recover our payments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. H. STATUTORY PROVISIONS These statements apply where they are required by law. 1. AS between an injured worker and us, we have notice of the injury when you have notice. 2. Your default or the bankruptcy or insolvency of you or your estate will not relieve us of our duties under this insurance after an injury occurs. 3. We are directly and primarily liable to any person entitled to the benefits payable by this insurance. Those persons may enforce our duties; so may an agency authorized by law. Enforcement may be against us or against you and us. 4. Jurisdiction over you is jurisdiction over us for purposes of the workers compensation law. We are bound by decisions against you under that law, subject to the provisions of this policy that are not in conflict with that law. 5. This insurance conforms to the parts of the workers compensation law that apply to: a. benefits payable by this insurance or; b. special taxes, payments into security or other special funds, and assessments payable by us under that law. 6. Terms of this insurance that conflict with the workers compensation law are changed by this statement to conform to that law. Nothing in these paragraphs relieves you of your duties under this policy. PART TWO - EMPLOYERS LIABILITY INSURANCE A. HOW THIS INSURANCE APPLIES This employers liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must arise out of and in the course of the injured employee's employment by you. 2. The employment must be necessary or incidental to your work in a state or territory listed in Item 3.A. of the Information Page. 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. If you are sued, the original suit and any related legal actions for damages for bodily injury WC 00 00 00 A 2 of 7 INSURED'S COPY by accident or by disease must be brought in the United States of America, its territories or possessions, or Canada. 3. WE WILL PAY We will pay all sums you legally must pay as damages because of bodily injury to your employees, provided the bodily injury is covered by this Employers Liability Insurance. The damages we will pay, where recovery is permitted by law, include damages: 1. for which you are liable to a third party by reason of a claim or suit against you by that third party to recover the damages claimed against such third party as a result of injury to your employee; 2. for care and loss of services; and 3. for consequential bodily injury to a spouse, child, parent, brother or sister of the injured employee; provided that these damages are the direct consequence of bodily injury that arises out of and in the course of the injured employee's employment by you; and 4. because of bodily injury to your employee that arises out of and in the course of employment, claimed against you in a capacity other than as employer. C. EXCLUSIONS This insurance does not cover: 1. liability assumed under a contract. This exclusion does not apply to a warranty that your work will be done in a workmanlike manner; 2. punitive or exemplary damages because of bodily injury to an employee employed in violation of law; 3. bodily injury to an employee while employed in violation of law with your actual knowledge or the actual knowledge of any of your executive officers; 4. any obligation imposed by a workers compensation, occupational disease, unemployment compensation, or disability benefits law, or any similar law; 5. bodily injury intentionally caused or aggravated by you; 6. bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America or Canada who is temporarily outside these countries; 7. damages arising out of coercion, criticism, demotion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimination against or termination of any employee, or any personnel practices, policies, acts or omissions. 8. bodily injury to any person in work subject to the Longshore and Harbor Workers' Compensation Act (33 USC Sections 901-950), the Nonappropriated Fund Instrumentalities Act (5 USC Sections 8171-8173), the Outer Continental Shelf Lands Act (43 USC Sections 1331-1356), the Defense Base Act (42 USC Sections 1651-1654), the Federal Coal Mine Health and Safety Act of 1969 (30 USC Sections 901-942), any other federal workers or workmen's compensation law or other federal occupational disease law, or any amendments to these laws. 9. bodily injury to any person in work subject to the Federal Employers' Liability Act (45 USC Sections 51-60), any other federal laws obligating an employer to pay damages to an employee due to bodily injury arising out of or in the course of employment, or any amendments to those laws. 10. bodily injury to a master or member of the crew of any vessel. 11. fines or penalties imposed for violation of federal or state law. 12. damages payable under the Migrant and Seasonal Agricultural Worker Protection Act (29 USC Sections 1801-1872) and under any other federal law awarding damages for violation of those laws or regulations issued thereunder, and any amendments to those laws. D. WE WILL DEFEND We have the right and duty to defend, at our expense, any claim, proceeding or suit against you for damages payable by this insurance. We have the right to investigate and settle these claims, proceedings and suits. WC 00 00 00 A 3 of 7 INSURED'S COPY We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. We have no duty to defend or continue defending after we have paid our applicable limit of liability under this insurance. E. WE WILL ALSO PAY We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim proceeding, or suit we defend; 1. reasonable expenses incurred at our request; but not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the limit of our liability under this insurance; 3. litigation costs taxed against you; 4. interest on a judgment as required by law until we offer the amount due under this insurance; and 5. expenses we incur. F. OTHER INSURANCE We will not pay more than our share of damages and costs covered by this insurance and other insurance or self-insurance. Subject to any limits of liability that apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted', the shares of all remaining insurance and self-insurance will be equal until the loss is paid. G. LIMITS OF LIABILITY Our liability to pay for damages is limited. Our limits of liability are shown in Item 3.B. of the Information Page. They apply as explained below. 1. Bodily Injury by Accident. The limit shown for "bodily injury by accident-each accident" is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident. A disease is not bodily injury by accident unless it results directly from bodily injury by accident. 2. Bodily Injury by Disease. The limit shown for "bodily injury by disease-policy limit" is the most we will pay for all damages covered by this insurance and arising out of bodily injury by disease, regardless of the number of employees who sustain bodily injury by disease. The limit shown for "bodily injury by disease each employee" is the most we will pay for all damages because of bodily injury by disease to any one employee. Bodily injury by disease does not include disease that results directly from a bodily injury by accident. 3. We will not pay any claims for damages after we have paid the applicable limit of our liability under this insurance. H. RECOVERY FROM OTHERS We have your rights to recover our payment from anyone liable for an injury covered by this insurance. You will do everything necessary to protect those rights for us and to help us enforce them. I. ACTIONS AGAINST US There will be no right of action against us under this insurance unless: 1. You have complied with all the terms of this policy; and 2. The amount you owe has been determined with our consent or by actual trial and final judgment. This insurance does not give anyone the right to add us as a defendant in an action against you to determine your liability. The bankruptcy or insolvency of you or your estate will not relieve us of our obligations under this Part. PART THREE - OTHER STATES INSURANCE A. HOW THIS INSURANCE APPLIES 1. This other states insurance applies only if one or more states are shown in Item 3.C. of the Information Page. 2. If you begin work in any one of those states after the effective date of this policy and are not insured or are not self-insured for such work, all provisions of the policy will apply as though that state were listed in Item 3.A. of the Information Page. 3. We will reimburse you for the benefits required by the workers compensation law of that state if we are not permitted to pay the benefits directly to persons entitled to them. 4. If you have work on the effective date of this policy in any state not listed in Item 3.A. of the WC 00 00 00 A 4 of 7 INSURED'S COPY Information Page, coverage will not be afforded for that state unless we are notified within thirty days. B. NOTICE Tell us at once if you begin work in any state listed in Item 3.C. of the Information Page. PART FOUR - YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered by this policy. Your other duties are listed here. 1. Provide for immediate medical and other services required by the workers compensation law. 2. Give us or our agent the names and addresses of the injured persons and of witnesses, and other information we may need. 3. Promptly give us all notices, demands and legal papers related to the injury, claim, proceeding or suit. 4. Cooperate with us and assist us, as we may request, in the investigation, settlement or defense of any claim, proceeding or suit. 5. Do nothing after an injury occurs that would interfere with our right to recover from others. 6. Do not voluntarily make payments, assume obligations or incur expenses, except at your own cost. PART FIVE - PREMIUM A. OUR MANUALS All premium for this policy will be determined by our Manuals of rules, rates, rating plans and classifications. We may change our manuals and apply the changes to this policy if authorized by law or a governmental agency regulating this insurance. B. CLASSIFICATIONS Item 4 of the Information Page shows the rate and premium basis for certain business or work classifications. These classifications were assigned based on an estimate of the exposures you would have during the policy period. If your actual exposures are not properly described by those classifications, we will assign proper classifications, rates and premium basis by endorsement to this policy. C. REMUNERATION Premium for each work classification is determined by multiplying a rate times a premium basis. Remuneration is the most common premium basis. This premium basis includes payroll and all other remuneration paid or payable during the policy period for the services of: 1. All your officers and employees engaged in work covered by this policy; and 2. All other persons engaged in work that could make us liable under Part One (Workers Compensation Insurance) of this policy. If you do not have payroll records for these persons, the contract price for their services and materials may be used as the premium basis. This paragraph 2 will not apply if you give us proof that the employers of these persons lawfully secured their workers compensation obligations. D. PREMIUM PAYMENTS You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. E. FINAL PREMIUM The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the balance. If it is less, we will refund the balance to you. The final premium will not be less than the highest minimum premium for the classifications covered by this policy. If this policy is canceled, final premium will be determined in the following way unless our manuals provide otherwise. 1. If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. 2. If you cancel, final premium will be more than pro rata; it will be based on the time this policy was in force, and increased by our short rate WC 00 00 00 A 5 of 7 INSURED'S COPY cancellation table and procedure. Final premium will not be less than the minimum premium. F. RECORDS You will keep records of information needed to compute premium. You will provide us with copies of those records when we ask for them. G. AUDIT You will let us examine and audit all your records that relate to this policy. These records include ledgers, journals, registers, vouchers, contracts, tax reports, payroll and disbursement records, and programs for storing and retrieving data. We may conduct the audits during regular business hours during the policy period and within three years after the policy period ends. Information developed by audit will be used to determine final premium. Insurance rate service organizations have the same rights we have under this provision. PART SIX - CONDITIONS A. INSPECTION We have the right, but are not obliged to inspect your workplaces at any time. Our inspections are not safety inspections. They relate only to the insurability of the workplaces and the premiums to be charged. We may give you reports on the conditions we find. We may also recommend changes. While they may help reduce losses, we do not undertake to perform the duty of any person to provide for the health or safety of your employees or the public. We do not warrant that your workplaces are safe or healthful or that they comply with laws, regulations, codes or standards. Insurance rate service organizations have the same rights we have under this provision. B. LONG TERM POLICY If the policy period is longer than one year and sixteen days, all provisions of this policy will apply as though a new policy were issued on each annual anniversary that this policy is in force. C. TRANSFER OF YOUR RIGHTS AND DUTIES Your rights or duties under this policy may not be transferred without our written consent. If you die and we receive notice within thirty days after your death, we will cover your legal representative as insured. D. CANCELLATION 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancellation is to take effect. 2. We may cancel this policy. We must mail or deliver to you not less than ten days advance written notice stating when the cancellation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 3. The policy period will end on the day and hour stated in the cancellation notice. 4. Any of these provisions that conflicts with a law that controls the cancellation of the insurance in this policy is changed by this statement to comply with that law. E. SOLE REPRESENTATIVE The insured first named in Item 1 of the Information Page will act on behalf of all insureds to change this policy, receive return premium, and give or receive notice of cancellation. WC 00 00 00 A 6 of 7 INSURED'S COPY' IN WITNESS WHEREOF, the company has caused this policy to be executed and attested, but this policy shall not be valid unless countersigned by a duly authorized representative of the company. /s/ WILLIAM D. SMITH /s/ [ILLEGIBLE] -------------------- --------------- President President The Insurance Company National Union Fire of The State of Pennsylvania Insurance Company of Birmingham Fire Insurance Pittsburg, PA Company of Pennsylvania /s/ WALTER L MOONEY /s/ [ILLEGIBLE] ------------------- --------------- President President Commerce and Industry American Home Insurance Company Assurance Company /s/ ELIZABETH M. TUCK --------------------- Secretary National Union Fire Insurance Company of Pittsburgh, PA American Home Assurance Company The Insurance Company of The State of Pennsylvania Birmingham Fire Insurance Company of Pennsylvania Commerce and Industry Insurance Company WC 00 00 00 A 7 of 7 INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-44 ARIZONA - ------------------- --------------- ------------------------------ POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY SYNADYNE I JOB SITE ONLY PHOENIX, AZ 85O16 CLERICAL OFFICE EMPLOYEES NOC 8810 3,726,500 0.47 17,515 LABOR WORLD OF AMERICA, INC 5343 NORTH 16TH ST., STE 33 PHOENIX, AZ 85O16 FARM: NURSERY EMPLOYEES & DRIVERS 0005D 100 4.23 4 INCLUDES INCIDENTAL LANDSCAPE GARDENING LANDSCAPE GARDENING & DRIVERS 0042 38,200 8.00 3,056 CODES 0042 AND 9102 PARK NOC MAY BE ASSIGNED TO THE SAME RISK. THE PAYROLL OF AN INDIVIDUAL EMPLOYEE MAY BE DIVIDED AND ALLOCATED BETWEEN CODES 0042 AND 9102 PROVIDED THAT THE ENTRIES ON THE ORIGINAL RECORDS OF THE INSURED DISCLOSE AN ALLOCATION OF EACH INDIVIDUAL'S PAYROLL. AN ESTIMATE OR PERCENTAGE ALLOCATION OF PAYROLL IS NOT PERMITTED BAKERY & DRIVERS, ROUTE SUPERVISORS 2003D 154,000 7.64 11,766 GRAIN MILLING 2014D 23,200 10.54 2,445 BOTTLING NOC & ROUTE SUPERVISORS, 2157 28,200 6.09 1,717 DRIVERS NET MFG 2380 1,500 3.48 52 AWNING OR TENT MFG - SHOP 2576 21,800 5.34 1,164 RUG, CARPET OR UPHOLSTERY CLEANING 2585 10,100 6.92 699 CLEANING OR DYEING & ROUTE SUPERVISORS, 2586 6,400 2.86 183 ______SMEN, DRIVERS - ------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-44 ARIZONA - ------------------- --------------- ------------------------------ POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY FURNITURE STOCK MFG 2735 200 14.48 29 CABINET WORKS - WITH POWER MACHINERY 2812D 2,700 7.73 209 SHADE ROLLER MFG - WOOD 2841 200 6.96 14 FURNITURE ASSEMBLING-WOOD-FROM 2881 1,400 5.11 72 MANUFACTURED PARTS PHONOGRAPH CABINET MFG 2883D 600 5.85 35 PIPE OR TUBE MFG - IRON OR STEEL - NOT 3028 2,400 6.17 148 CAST IRON - & DRIVERS IRON WORKS SHOP DECORATIVE & 3041 150 7.52 11 FOUNDRIES SHEET METAL WORK SHOP 3066D 700 8.22 58 METAL EQUIPMENT MFG 3076D 900 5.95 54 SCREW MFG 3145 17,400 3.89 677 SKATE MFG 3146 4,600 4.66 214 HEATER OR RADIATOR MFG 3175 2,300 2.81 65 SPRING MFG 3303 600 4.78 29 AGRICULTURAL OR CONSTRUCTION MACHINERY 3507 9,400 4.81 452 MFG COMPUTING, RECORDING OR OFFICE MACHINE 3574D 600 1.27 8 MFG NOC PUMP MFG 3612D 11,800 9.08 1,071 MACHINE SHOP NOC 3632D 200 3.69 7 ELECTRICAL APPARATUS INSTALLATION OR 3724D 700 9.28 65 REPAIR & DRIVERS CONCRETE PRODUCTS MFG & DRIVERS 4034D 2,400 10.68 256 - ------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-44 ARIZONA - ------------------- --------------- ------------------------------ POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY PLASTER BOARD OR PLASTER BLOCK MFG & 4036 200 5.84 12 DRIVERS GLASS MFG-CUT 4113 300 2.94 9 COMPUTER CHIP MFG 4150 200 1.92 4 BOX MFG - FOLDING PAPER - NOC 4243 5,300 6.63 351 PAPER GOODS MFG NOC 4279 700 8.93 63 PRINTING 4299D 500 3.51 18 BONE OR IVORY GOODS MFG 4452D 4,900 5.40 265 PLASTICS MFG: SHEETS RODS OR TUBES 4459 19,500 4.06 792 _____ MFG 4558 200 7.06 14 SOAP OR SYNTHETIC DETERGENT MFG 4720 3,800 3.87 147 PHARMACEUTICAL, DRUG OR MEDICINE 4825 900 1.57 14 PREPARATION MFG & INCIDENTAL MFG OF INGREDIENTS SPORTING GOODS MFG NOC 4902 300 2.71 8 AUDIO OR VISUAL RECORDING MEDIA MFG 4923 900 2.96 27 INCLUDES TAPES OR DISKS, PHONOGRAPH RECORD MFG. TO BE SEPARATELY RATED AS CODE 4431 PLASTERING OR STUCCO WORK-ON OUTSIDE OF 5022D 14,200 15.15 2,151 BUILDINGS FURNITURE OR FIXTURES INSTALLATION - 5146 70,400 10.19 7,174 PORTABLE - NOC PLUMBING NOC & DRIVERS 5183 112,800 8.87 10,005 AIR CONDITIONING SYSTEMS NON-PORTABLE 5190 6,100 7.75 473 AND DRIVERS CONCRETE WORK-INCIDENTAL TO THE 5215D 500 8.22 41 - ------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-45 CALIFORNIA - ------------------- --------------- ------------------------------ POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID 3170801 ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY GASOLINE RECOVERY--FROM CASING 4740 6,400 3.13 200 HEAD OR NATURAL GAS CHEMICAL MIXING, BLENDING AND 4828 600 6.36 38 REPACKAGING ONLY-NOT MANUFACTURING OF INGREDIENTS IRON, STEEL, BRASS, BRONZE OR 5102 73,000 12.66 9,242 ALUMINUM ERECTION-NON-STRUCTURAL- WITHIN BUILDINGS INSTRUMENT-PROFESSIONAL OR SCIENTIFIC-- 5128 6,000 2.42 145 INSTALLATION, SERVICE OR REPAIR--AWAY FROM SHOP--NOT OFFICE MACHINES CABINET OR FIXTURES-PORTABLE; INTERIOR 5146 340,800 7.88 26,855 _____--INSTALLATION--N.O.C.--N.P.D WITH "CARPENTRY"; 5697, "CARPENTRY"; 5403, "CARPENTRY"; OR 5432, "CARPENTRY" TELEPHONE OR TELEPHONE SYSTEM 5191 7,800 3.48 271 INSTALLATION, SERVICE OR REPAIR SHOP AND OUTSIDE CONCRETE OR CEMENT WORK POURING OR 5201 1,200 11.23 135 FINISHING OF CONCRETE SIDEWALKS, DRIVEWAYS, PATIOS, CURBS OR GUTTERS - INCLUDING THE MAKING OR STRIPPING OF FORMS - EMPLOYEES WHOSE REGULAR HOURLY WAGE DOES NOT EQUAL OR EXCEED $18.00 PER HOUR CARPENTRY-EMPLOYEES WHOSE REGULAR HOURLY 5403 99,600 27.14 27,031 WAGE DOES NOT EQUAL OR EXCEED $18.00 PER HOUR - N.O.C WALLBOARD APPLICATION - WITHIN BUILDINGS 5446 600 14.85 89 INSTALLATION OR APPLICATION OF GYPSUM WALLBOARD - INCLUDING FINISHING AND PREPARATION PRIOR TO PAINTING - EMPLOYEES WHOSE REGULAR HOURLY WAGE DOES NOT EQUAL OR EXCEED $20.00 PER HOUR-- ___THIS CLASSIFICATION IS APPLICABLE TO - ------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-45 CALIFORNIA - ------------------- --------------- ------------------------------ POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID 3170801 ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY THE INSTALLATION OR APPLICATION OF INSULATING MATERIALS WITHIN THE BUILDING WALLS, BUT ONLY IF INSTALLED BY THE SAME EMPLOYER WHO WHO PERFORMS THE WALLBOARD APPLICATION IN CONSTRUCTING NEW BUILDINGS OR ADDITIONS TO EXISTING BUILDINGS AT THE SAME JOB OR LOCATIONS. STREET OR ROAD CONSTRUCTION-PAVING OR 5506 3,000 9.51 285 REPAVING, SURFACING OR RESURFACING OR SCRAPING-ALL KINDS-INCLUDING AIRPORT RUNWAYS, WARMING APRONS, INCIDENTAL FIELD PLANTS, FENCE OR GUARD RAIL CONSTRUCTION STREET OR ROAD CONSTRUCTION-GRADING- 5507 1,200 6.11 73 ALL OPERATIONS OF BRINGING ROADBED TO GRADE, INCLUDING CLEARING AND GRUBBING RIGHT-OF-WAY AND TEMPORARY SURFACING SHEET METAL WORK--ERECTION, INSTALLATION 5538 5,300 14.87 788 OR REPAIR--SHOP AND OUTSIDE--INCLUDING INSTALLATION OF FURNACES OR AIR-CONDITIONING SYSTEMS--EMPLOYEES WHOSE REGULAR HOURLY WAGE DOES NOT EQUAL OR EXCEED $19.00 PER HOUR--N.O.C THIS CLASSIFICATION IS APPLICABLE TO THE INSTALLATION OF SHEET METAL ROOFING, BUT ONLY IF INSTALLED BY THE SAME EMPLOYER WHO PERFORMS THE SHEET METAL SKINNING IN CONSTRUCTING NEW BUILDINGS OR ADDITIONS TO EXISTING BUILDINGS AT THE SAME JOB OR LOCATION. ALL OTHER ROOFING SHALL BE SEPARATELY RATED EXCAVATION--N.O.C.--INCLUDING BORROWING, 6218 900 9.26 83 FILLING OR BACKFILLING - EMPLOYEES WHOSE REGULAR HOURLY WAGE DOES NOT EQUAL OR EXCEED $22.00 PER HOUR MASS ROCK EXCAVATION, GRADING OR EXCAVATION IN CONNECTION WITH STREET OR ROAD CONSTRUCTION, PILE DRIVING, SHAFT SINKING, CAISSON OR COFFERDAM WORK SHALL BE SEPARATELY RATED SEWER CONSTRUCTION - ALL OPERATIONS-- 6307 300 10.29 3__ - ------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-45 CALIFORNIA - ------------------- --------------- ------------------------------ POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID 3170801 ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY INCLUDING CONSTRUCTION OF LATERALS AND TUNNELING AT STREET CROSSINGS - EMPLOYEES WHOSE REGULAR HOURLY WAGE DOES NOT EQUAL OR EXCEED $20.00 PER HOUR. CONFECTIONS AND FOOD SUNDRIES MFG OR 6504 387,200 8.59 33,260 PROCESSING-N.O.C MOBILE CRANE AND HOISTING SERVICE 7219 140,000 14.16 19,824 CONTRACTORS-N.O.C.-ALL OPERATIONS-- INCLUDING YARD EMPLOYEES FREIGHT HANDLERS-PACKING OR HANDLING 7360 5,800 13.06 757 MERCHANDISE AT SHIPPING OR RECEIVING TERMINALS--N.O.C WATERWORKS-OPERATION--ALL EMPLOYEES-- 7520 23,200 5.29 1,227 INCLUDING CONSTRUCTION OR EXTENSION OF SANITARY OR SANITATION DISTRICTS 7580 263,400 3.33 8,771 OPERATION-ALL EMPLOYEES TELECOMMUNICATIONS COMPANIES--ALL 7600 2,500 2.60 65 EMPLOYEES--INCLUDING INSTALLATION, MAINTENANCE, REPAIR AND OPERATION OF TELEPHONE LINES AND SYSTEMS, REMOTE TRANSMISSION SITES, AND CENTRAL OFFICE SWITCHING EQUIPMENT--INCLUDING SHOP RADIO, TELEVISION OR COMMERCIAL 7610 2,500 1.19 30 BROADCASTING STATIONS-ALL EMPLOYEES- INCLUDING CLERICAL OFFICE EMPLOYEES AND SALESPERSONS THE ACTUAL REMUNERATION OF PLAYERS, ENTERTAINERS OR MUSICIANS MUST BE USED UNLESS THE AMOUNT EXCEEDS $1,250 PER WEEK, IN WHICH EVENT $1,250 SHALL BE USED AS REPRESENTING THE ACTUAL WEEKLY REMUNERATION OF EACH PLAYER, ENTERTAINER OR MUSICIAN MOTION PICTURE PRODUCTION SHALL BE SEPARATELY CLASSIFIED STORES-FLORISTS-INCLUDING SERVICE 8001 25,500 5.64 1,438 - ------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-45 CALIFORNIA - ------------------- --------------- ------------------------------ POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID 3170801 ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY AWAY FROM PREMISES STORES-CLOTHING,WEARING APPAREL OR DRY 8008 30,600 3.99 1,221 GOODS--RETAIL--INCLUDING ALTERATION DEPARTMENT STORES--FURNITURE--WHOLESALE OR RETAIL 8015 20,000 7.13 1,426 STORES -- RETAIL -- N.O.C 8017 83,200 4.78 3,977 STORES--DEPARTMENT STORES--RETAIL-- 8039 150 4.28 6 INCLUDING CLERICAL OFFICE EMPLOYEES AND SALESPERSONS STORES--WINE OR SPIRITS--WHOLESALE-- 8041 10,900 9.26 1,009 INCLUDING BLENDING, RECTIFYING, DISTILLING OR BOTTLING _____FLOOR COVERING -- WHOLESALE OR 8042 800 5.74 46 RETAIL CARPET RUGS, VINYL OR LINOLEUM STORES--AUTOMOBILE ACCESSORIES-- 8046 6,200 4.85 301 WHOLESALE OR RETAIL--INCLUDING INSIDE OR OUTSIDE SALESPERSONS STORES COMPUTER -- WHOLESALE OR 8062 14,000 1.98 277 RETAIL--INCLUDING OUTSIDE SALESPERSONS STORES LIGHTING FIXTURES -- WHOLESALE 8063 1,600 5.29 85 OR RETAIL STORES -- VIDEOTAPE -- RENTAL OR SALE -- 8070 15,400 2.29 353 RETAIL THIS CLASSIFICATION SHALL APPLY TO EACH SEPARATE STORE LOCATION AT WHICH THE RENTAL OR SALE OF VIDEO SOFTWARE EQUALS OR EXCEEDS 75% OF GROSS RECEIPTS IRON OR STEEL MERCHANTS-NOT JUNK 8106 3,000 10.76 323 DEALERS OR IRON OR STEEL SCRAP DEALERS MACHINERY DEALERS-N.O.C.-INCLUDING 8107 16,600 4.65 772 CONSTRUCTION AND REPAIR - ------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-45 CALIFORNIA - ------------------- --------------- ------------------------------ POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID 3170801 ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY CONSTRUCTION OR ERECTION PERMANENT YARDS 8227 68,000 7.72 5,265 - -FOR MAINTENANCE OF EQUIPMENT OR STORAGE OF MATERIAL BUILDING MATERIAL DEALERS-COMMERCIAL- 8232 100,300 9.66 9,689 NO SECONDHAND MATERIALS SALVAGE MATERIAL DEALERS: 8264 508,200 13.64 69,318 PAPER STOCK DEALERS--SECONDHAND MACHINERY AND EQUIPMENT 8267 78,500 13.00 10,205 DEALERS-SECONDHAND-INCLUDING INCIDENTAL RECONDITIONING OR REPAIRING WAREHOUSE--SELF STORAGE--ALL OTHER 8290 200 8.89 18 EMPLOYEES--INCLUDING ON-SITE MANAGERS, _____DENT EMPLOYEES AND RESIDENT CLERICAL _____CE EMPLOYEES WHEN LODGING IS PROVIDED BY THE EMPLOYER, THE TOTAL REMUNERATION SHALL INCLUDE THE MARKET VALUE OF SUCH LODGING TO THE EMPLOYEE WAREHOUSES-COLD STORAGE 8291 6,300 7.44 469 WAREHOUSES-GENERAL MERCHANDISE-N.O.C 8292 330,800 15.84 52,339 WAREHOUSES--FURNITURE--INCLUDING 8293 46,500 23.38 10,872 PACKING OR HANDLING HOUSEHOLD GOODS AWAY FROM INSURED'S PREMISES ELEVATOR SERVICE INSPECTIONS, OILING 8729 800 1.92 15 AND ADJUSTING--NO REPAIR APARTMENT OR CONDOMINIUM COMPLEX 8740 17,800 0.54 96 OPERATION--PROPERTY MANAGEMENT SUPERVISORS - --NOT RESIDENT OR ON-SITE MANAGERS OR SUPERVISORS THIS CLASSIFICATION APPLIES TO OFF-SITE PROPERTY MANAGEMENT SUPERVISORS WHO EXERCISE DIRECTION THROUGH RESIDENT OR ON-SITE APARTMENT OR CONDOMINIUM COMPLEX MANAGERS. THIS CLASSIFICATION ALSO APPLIES TO OFF-SITE PROPERTY MANAGEMENT - ------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-45 CALIFORNIA - ------------------- --------------- ------------------------------ POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID 3170801 ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY SUPERVISORS WHO OVERSEE APARTMENT OR CONDOMINIUM COMPLEXES AT WHICH ALL OPERATION, MAINTENANCE AND CARE ACTIVITIES ARE CONDUCTED BY SEPARATE CONCERNS AND NO PAYROLL IS DEVELOPED UNDER CODE 9011, "APARTMENT OR CONDOMINIUM COMPLEX OPERATION". SALESPERSONS--OUTSIDE 8742 576,400 0.87 5,015 MAILING OR ADDRESSING 8800 86,900 5.43 4,719 COMPANIES-INCLUDING CLERICAL OFFICE EMPLOYEES-N P D AUDITORS, ACCOUNTANTS, FACTORY COST OR 8803 400 0.46 2 OFFICE SYSTEMATIZERS-ALL EMPLOYEES-INCLUDING CLERICAL OFFICE EMPLOYEES--N.P.D NEWSPAPER, MAGAZINE OR BOOK PUBLISHING-- 8807 35,500 1.57 557 NO PRINTING--EDITING, DESIGNING, PROOFREADING AND PHOTOGRAPHIC COMPOSING-- INCLUDING CLERICAL OFFICE EMPLOYEES CLERICAL OFFICE EMPLOYEES-N.O.C 8810 2,214,000 0.77 17,048 PRINTING OPERATION--EDITING, DESIGNING, 8813 135,200 0.88 1,190 PROOFREADING AND PHOTOGRAPHIC COMPOSING - --INCLUDING CLERICAL OFFICE EMPLOYEES INSTITUTIONAL EMPLOYEES - HOSPITALS, 8830 1,200 3.03 36 SANITARIUMS, REST HOMES OR HOMES FOR THE AGED--ALL EMPLOYEES--INCLUDING CLERICAL OFFICE EMPLOYEES AND SALESPERSON--NOT JAIL OR PRISION EMPLOYEES IN DETERMINING THE PREMIUM CHARGE FOR STUDENT NURSES OR INTERNES, SUCH PREMIUMS SHALL BE COMPUTED ON THE BASIS OF AN AVERAGE WAGE OF AT LEAST $100 PER WEEK JANITORIAL SERVICES - BY CONTRACTORS 9008 64,800 12.40 8,035 BUILDING OPERATION --COMMERCIAL 9009 6,400 6.24 399 PROPERTIES--ALL OTHER EMPLOYEES - ------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-45 CALIFORNIA - ------------------- --------------- ------------------------------ POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID 3170801 ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY NEW CONSTRUCTION, ALTERATION, OR DEMOLITION WORK SHALL BE SEPARATELY RATED. THE PREPARATION OR SERVING OF HOT FOODS SHALL BE SEPARATELY RATED AS 9079(l), "RESTAURANTS". BUILDING OPERATION--N.O.C.--ALL OTHER 9015 47,300 8.89 4,205 EMPLOYEES--INCLUDING RESIDENT OR ON-SITE MANAGERS WHEN LODGING IS PROVIDED BY THE EMPLOYER, THE TOTAL REMUNERATION SHALL INCLUDE THE MARKET VALUE OF SUCH LODGING TO THE EMPLOYEE FLATS, APARTMENTS, OR MULTIPLE DWELLINGS HAVING FOUR OR MORE UNITS ARE SUBJECT TO A MINIMUM PAYROLL OF $2000 PER ___UM FOR ONE LOCATION AND TO A MINIMUM ___$1000 FOR EACH ADDITIONAL LOCATION COVERED BY THE SAME POLICY AMUSEMENT PARKS OR EXHIBITIONS--CARE, 9016 1,500 6.57 99 CUSTODY AND MAINTENANCE OF PREMISES; OPERATION OF ELEVATORS OR HEATING, LIGHTING OR POWER APPARATUS--INCLUDING POLICEMEN, WATCHMEN, MUSICIANS, BOX OFFICE EMPLOYEES, TICKET SELLERS OR GATE ATTENDANTS HOSPITALS--ALL EMPLOYEES--INCLUDING 9043 80,100 3.03 2,427 CLERICAL OFFICE EMPLOYEES AND SALESPERSONS IN DETERMINING THE PREMIUM CHARGE FOR STUDENT NURSES OR INTERNES, SUCH PREMIUMS SHALL BE COMPUTED ON THE BASIS OF AN AVERAGE WAGE OF AT LEAST $100 PER WEEK CLUBS--COUNTRY OR GOLF--ALL EMPLOYEES-- 9060 5,800 6.32 367 INCLUDING RESTAURANT OR TAVERN EMPLOYEES RESIDENTIAL CLEANING SERVICES--BY 9096 200 15.09 30 CONTRACTORS COLLEGES OR SCHOOLS--PRIVATE NOT 9101 450 6.22 28 - ------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-45 CALIFORNIA - ------------------- --------------- ------------------------------ POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID 3170801 ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY AUTOMOBILE SCHOOLS--ALL EMPLOYEES OTHER THAN PROFESSORS, TEACHERS OR PROFESSIONAL EMPLOYEES--INCLUDING CAFETERIAS CEMETERY OPERATION-ALL EMPLOYEES 9220 14,500 8.82 1,279 GARBAGE, ASHES OR REFUSE COLLECTING 9403 44,500 11.97 5,327 GARBAGE, ASHES OR REFUSE DUMP 9424 125,300 9.61 12,041 OPERATIONS-ALL EMPLOYEES HOUSEHOLD APPLIANCES--ELECTRICAL-- 9519 18,300 6.47 1,184 INSTALLATION, SERVICE OR REPAIR HOUSE FURNISHINGS-N.O.C.-- 9521 12,100 10.21 1,235 INSTALLATION-INCLUDING UPHOLSTERING ____FOLDS, SHORING, CONCRETE OR CEMENT 9529 18,600 15.58 2,898 ____TRIBUTING TOWERS, HOD HOISTS OR CONSTRUCTION ELEVATORS-INSTALLATION OR REMOVAL ADVERTISING COMPANIES-OUTDOOR-SELLING 9549 100 9.03 9 SPACE FOR ADVERTISING PURPOSES-INCLUDING SHOP OPERATIONS, AND THE ERECTION, PAINTING, REPAIR, MAINTENANCE, OR REMOVAL OF SIGNS; BILL POSTING; SIGN PAINTING OR LETTERING IN OR UPON BUILDINGS OR STRUCTURES LABOR WORLD OF AMERICA, INC. (A CORP.) 2413 SOUTH GARFIELD AVENUE MONTEREY PARK, CA 91754 CLERICAL OFFICE EMPLOYEES-N.O.C 8810 9,000 0.77 69 - ------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-45 CALIFORNIA - ------------------- --------------- ------------------------------ POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID 3170801 ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS CODE ESTIMATED TOTAL PER $100 OF ESTIMATED SPECIFICALLY PROVIDED ELSEWHERE IN NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS THIS POLICY, DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY UNMODIFIED PREMIUM 707,352 TOTAL UNMODIFIED PREMIUM 707,352 EXPERIENCE MODIFICATION (ACTUAL) 2.26 9898 891,264 SCHEDULE MODIFICATION 65% 9887 (1,039,100) MODIFIED STANDARD PREMIUM 559,516 LOSS REIMBURSEMENT $250,000 9862 (268,662) UNDISCOUNTED PREMIUM 559,516 EXPENSE CONSTANT 0900 160 TOTAL ESTIMATED ANNUAL PREMIUM 291,014 CA UF SURCHARGE .2548% 0088 1,426 CA FRAUD SURCHARGE .4242% 0088 2,374 TOTAL DUE 294,814 - ------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY LARGE RISK RATING PLAN ENDORSEMENT (SHORT FORM) This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-45 Issued to OUTSOURCE INTERNATIONAL, INC. (A CORP.) By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA The premium for this policy will be determined according to the Large Risk Rating Plan Endorsement attached to policy NO. RMWC 2177940 53820 COUNTERSIGNED BY ____________________________ (ED. 07-92) AUTHORIZED REPRESENTATIVE INSURED'S COPY DEFENSE BASE ACT COVERAGE ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different @ate is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-45 Issued to OUTSOURCE INTERNATIONAL, INC. (A CORP.) By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the work described in the Schedule or described on the Information Page as subject to the Defense Base Act. The policy applies to that work as though the location included in the description of the work were a state named in Item 3.A. of the Information Page. General Section C. WORKERS' COMPENSATION LAW is replaced by the following: C. WORKERS' COMPENSATION LAW Workers' Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page and the Defense Base Act (42 USC Sections 1651-1654). It includes any amendments to those laws that are in effect during the policy period. It does not include any other federal workers or workmen's compensation law, other federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. Part Two (Employers Liability Insurance), C. Exclusions., exclusion 8, does not apply to work subject to the Defense Base Act. Schedule DESCRIPTION OF WORK NO WORK AT THIS TIME. IT IS AGREED THAT IF ANY WORK IS SUBJECT TO THE DEFENSE BASE ACT, THE INSURER WILL ENDORSE THE POLICY WITHIN SIXTY (60) DAYS OF NOTIFICATION. WC 00 01 01 A COUNTERSIGNED BY _____________________________ (ED. 4-92) AUTHORIZED REPRESENTATIVE INSURED'S COPY CALIFORNIA WORKERS COMPENSATION FRAUD ASSESSMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-45 Issued to OUTSOURCE INTERNATIONAL, INC. (A CORP.) By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA In order to fund increased investigation and prosecution of Workers Compensation fraud, Senate Bill 1218, statutes of 1990, created the Workers Compensation Fraud Account with the Insurance Fund administered by the Insurance Commissioner. The proceeds of this fund include this annual assessment collected from all insured and self insured employers, and remitted by your insurance company to the Workers Compensation Fraud Account. SURCHARGE FACTOR SURCHARGE AMOUNT .4242 $ 2374 56154WC (12-92) COUNTERSIGNED BY ______________________________ AUTHORIZED REPRESENTATIVE INSURED'S COPY CALIFORNIA - ADMINISTRATION REVOLVING FUND ASSESSMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-45 Issued to OUTSOURCE INTERNATIONAL, INC. (A CORP.) By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA California Law requires insurers who provide Workers' Compensation insurance to collect an Administration Revolving Fund Assessment for each insured employer. The percentage, as determined by the Director of the Department of Industrial Relations, is applied to each insured employer's premium for the purpose of determining its share of the assessment to be paid. This surcharge amount is subject to adjustment at audit. The Fund was established pursuant to the provisions of California Labor Code Section 62.5. Your policy has been surcharged by the amount/percent stated below: SURCHARGE AMOUNT: $1,426 SURCHARGE PERCENT: .2548 WC 04 00 02 A COUNTERSIGNED BY ___________________________ (ED. 8-91) AUTHORIZED REPRESENTATIVE INSURED'S COPY LONGSHOREMEN'S AND HARBOR WORKERS' COMPENSATION ACT COVERAGE ENDORSEMENT CALIFORNIA This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-45 Issued to OUTSOURCE INTERNATIONAL, INC. (A CORP.) By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to work subject to the Longshoremen's and Harbor Workers' Compensation Act in California. The policy applies to that work as though California were listed in Item 3.A. of the Information Page. The definition of workers compensation law includes the Longshoremen's and Harbor Workers' Compensation Act (33 USC Sections 901-950) and any amendment to that Act that is in effect during the policy period. This endorsement does not apply to work subject to the Defense Base Act, the Outer Continental Shelf Lands Act, or the Nonappropriated Fund Instrumentalities Act. The estimated premium for the Longshoremen's and Harbor Workers' Compensation Act coverage provided by this endorsement is as shown in the Schedule below or Item 4 of the Information Page. SCHEDULE ESTIMATED RATE PER ESTIMATED ANNUAL $100 OF ANNUAL CODE NO. CLASSIFICATION REMUNERATION REMUNERATION PREMIUM SEE California Schedule OF Operations TOTAL ESTIMATED ANNUAL PREMIUM WC 04 01 01 COUNTERSIGNED BY _____________________________ (ED. 4-84) AUTHORIZED REPRESENTATIVE INSURED'S COPY POLICY AMENDATORY ENDORSEMENT - CALIFORNIA This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-45 Issued to OUTSOURCE INTERNATIONAL, INC. (A CORP.) By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA It is agreed that, anything in the policy to the contrary notwithstanding, such insurance as is afforded by this policy by reason of the designation of California in Item 3 of the information page is subject to the following provisions: 1. MINORS ILLEGALLY EMPLOYED - NOT INSURED. This policy does not cover liability for additional compensation imposed on you under Section 4557, Division IV, Labor Code of the State of California, by reason of injury to an employee under sixteen years of age and illegally employed at the time of injury. 2. PUNITIVE OR EXEMPLARY DAMAGES-UNINSURABLE. This policy does not cover punitive or exemplary damages where insurance of liability therefor is prohibited by law or contrary to public policy. 3. INCREASE in INDEMNITY PAYMENT-UNINSURABLE. This policy does not cover an increase in indemnity payment as provided for in subdivision (e) of Section 4650 of the Labor Code, if the late indemnity payment which gives rise to the increase in the amount of payment is due less than seven (7) days after we receive the completed claim form from you. You are responsible for the amount of increase in indemnity payments not covered under this policy and will reimburse us for any increase in indemnity payment not covered under the policy when the aggregate total amount of the reimbursement payments paid in a policy year exceeds one hundred dollars ($100). 4. APPLICATION OF POLICY. Part One, "Workers' Compensation Insurance", A "How This Insurance Applies", is amended to read as follows: This workers' compensation insurance applies to bodily injury by accident or disease, including death resulting therefrom. Bodily injury by accident must occur during the policy period. Bodily injury by disease must be caused or aggravated by the conditions of your employment. Your employee's exposure to those conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. RATE CHANGES. This policy is issued by us and accepted by you with the agreement that you will accept any increase in premium or in the rates of premium which may be promulgated under any rating plan approved by the Insurance Commissioner of the State of California, and that the effective date of any such increase shall be the effective date thereof fixed in accordance with the provisions of any such rating plan so approved by the Insurance Commissioner. Also the rates used to determine the premium are subject to increase during the term of the policy if an increase in rates applicable to policies in force is approved by the Insurance Commissioner of the State of California, and that the effective date of any such increase shall be the date fixed by the Insurance Commissioner. 6. LONG TERM POLICY. If this policy is written for a period longer than one year, all the provisions of this policy shall apply separately to each consecutive twelve-month period or, if the first or last consecutive period is less than twelve months, to such period of less than twelve months, in the same manner as if a separate policy had been written for each consecutive period. 7. STATUTORY PROVISION. Your employee has a first lien upon any amount which becomes owing to you by us on account of this policy, and in the case of your legal incapacity or inability to receive the money and pay it to the claimant, we will pay it directly to the claimant. WC 04 03 01 A (ED. 1-91) 1 of 2 INSURED'S COPY It is further agreed that this policy, including all endorsements forming a part thereof, constitutes the entire contract of insurance. No condition, provision, agreement, or understanding not set forth in this policy or such endorsements shall affect such contract or any rights, duties, or privileges arising therefrom. Applicable to and forming part of Policy No. RM WC 217-79-45 Issued by the THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA To OUTSOURCE INTERNATIONAL, INC. (A CORP.) of BOCA RATON FL Dated at _________________________ this ________ day of ___________,19_____ Countersigned _____________________________________________________________ WC 04 03 01 A COUNTERSIGNED BY ______________________________ (ED. 1-91) AUTHORIZED REPRESENTATIVE 2 of 2 INSURED'S COPY VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT-CALIFORNIA This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-45 Issued to OUTSOURCE INTERNATIONAL, INC. (A CORP.) By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA If the employer named in item 1 of the Information Page has in his employment persons not entitled to compensation under Division 4 of of the Labor Code of the State of California, this policy shall operate as an election on the part of the employer to come under the compensation provisions of Division 4 with respect to those persons described in the Schedule below. This policy applies to those persons described in the Schedule below as employees. SCHEDULE NO SUCH PERSON AT THIS TIME. IT IS AGREED THAT IF ANY SUCH PERSON IS SUBJECT TO THE VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT, THE INSURER WILL ENDORSE THE POLICY WITHIN SIXTY (60) DAYS OF NOTIFICATION. WC 04 03 05 COUNTERSIGNED BY _________________________ (ED. 1-85) AUTHORIZED REPRESENTATIVE INSURED'S COPY EMPLOYERS' LIABILITY COVERAGE AMENDATORY ENDORSEMENT - CALIFORNIA This endorsement changes the policy to which it is attached effective on inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-45 Issued to OUTSOURCE INTERNATIONAL, INC. (A CORP.) by THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA Premium The insurance afforded by Part Two (Employers' Liability Insurance) by reason of designation of California in item 3 of the information page is subject to the following provisions: A. "How This Insurance Applies", is amended to read as follows: A. How This Insurance Applies This employers' liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury means a physical or mental injury, including resulting death. Bodily injury does not include emotional distress, anxiety, discomfort, inconvenience, depression, dissatisfaction or shock to the nervous system, unless caused by either a manifest physical injury or a disease with a physical dysfunction or condition resulting in treatment by a licensed physician and surgeon. 1. The bodily injury must arise out of and in the course of the injured employee's employment by you. 2. The employment must be necessary or incidental to your work in California. 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. If you are sued, the original suit and any related legal actions for damages for bodily injury by accident or by disease must be brought in the United States of America, its territories or possessions, or Canada. C. "Exclusions", is amended to read as follows: C. EXCLUSIONS This insurance does not cover: 1. liability assumed under a contract; 2. bodily injury to an employee while employed in violation of law with your actual knowledge or the actual knowledge of any of your executive officers; 3. any obligation imposed by a workers' compensation, occupational disease, unemployment compensation, or disability benefits law, or any similar law; 4. bodily injury intentionally caused or aggravated by you; 5. bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America or Canada who is temporarily outside these countries; 6. bodily injury arising out of termination of employment; 7. bodily injury arising out of the coercion, demotion, reassignment, discipline, defamation, harassment or humiliation of, or discrimination against any employee. WC 04 03 60 COUNTERSIGNED BY ____________________________ (ED. 8-86) AUTHORIZED REPRESENTATIVE INSURED'S COPY ANNIVERSARY RATING DATE ENDORSEMENT-CALIFORNIA This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-45 Issued to OUTSOURCE INTERNATIONAL, INC. (A CORP.) By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA The premium and rates for this policy, and the experience rating modification factor, if any, may change on your anniversary rating date shown in the Schedule. SCHEDULE ANNIVERSARY RATING DATE: MARCH (MONTH) 01 (DAY) 1997 (YEAR) WC 04 04 01 COUNTERSIGNED BY ___________________________ (ED. 8-84) AUTHORIZED REPRESENTATIVE INSURED'S COPY MANDATORY RATE CHANGE ENDORSEMENT-CALIFORNIA This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-45 Issued to OUTSOURCE INTERNATIONAL, INC. (A CORP.) By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA The premium and rates with respect to the insurance provided by this policy by reason of the designation of California in Item 3 of the Information Page are subject to change if ordered by the Insurance Commissioner of the State of California pursuant to Section 11737 of the California Insurance Code. WC 04 04 02 COUNTERSIGNED BY ___________________________ (ED. 01-95) AUTHORIZED REPRESENTATIVE INSURED'S COPY CALIFORNIA CANCELATION ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-45 Issued to OUTSOURCE INTERNATIONAL, INC. (A CORP.) By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the Information Page. The cancelation condition in Part Six (Conditions) of the policy is replaced by these conditions: CANCELATION 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancelation is to take effect. 2. We may cancel this policy for one or more of the following reasons: a. Non-payment of premium; b. Failure to report payroll; c. Failure to permit us to audit payroll as required by the terms of this policy or of a previous policy issued by us; d. Failure to pay any additional premium resulting from an audit of payroll required by the terms of this policy or any previous policy issued by us; e. Material misrepresentation made by you or your agent; f. Failure to cooperate with us in the investigation of a claim; g. Failure to comply with Federal or State safety orders; h. Failure to comply with written recommendations of our designated loss control representatives; i. The occurrence of a material change in the ownership of your business; j. The occurrence of any change in your business or operations that materially increases the hazard for frequency or severity of loss; k. The occurence of any change in your business or operation that requires additional or different classification for premium calculation; l. The occurrence of any change in your business or operation which contemplates an activity excluded by our reinsurance treaties. WC 04 06 01A (ED. 12-93) -1- INSURED'S COPY 3. If we cancel your policy for any of the reasons listed in (a) through (f), we will give you 10 days advance written notice, stating when the cancelation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information page will be sufficient to prove notice. If we cancel your policy for any of the reasons listed in items (g) through (1), we will give you 30 days advance written notice; however, we agree that in the event of cancelation and reissuance of a policy effective upon a material change in ownership or operations, notice will not be provided. 4. The policy period will end on the day and hour stated in the cancelation notice. WC 04 06 01 A COUNTERSIGNED BY ______________________________ (ED. 12-93) AUTHORIZED REPRESENTATIVE -2- INSURED'S COPY CALIFORNIA WORKERS' COMPENSATION INSURANCE NOTICE OF NON-RENEWAL This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-45 Issued to OUTSOURCE INTERNATIONAL, INC. (A CORP.) By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA Section 11664 of the California Insurance Code which becomes operative November 30, 1994 requires us in most instances to provide you with a notice of non-renewal, except as specified in paragraphs 1 through 6 below, if we elect to non-renew your policy. The notice is required to be be sent to you at least 30 days but not more than 120 days before the end of the policy period. If we fail to provide you the required notice, we are required to continue the coverage under the policy with no change in the premium rate until 60 days after we provide you with the required notice. We are not required to provide you with a notice of non-renewal in any of the following situations: 1. Your policy was transferred or renewed without a change in its terms or conditions or the rate on which the premium is based to another insurer or other insurers who are members of the same insurance group as us. 2. The policy was extended for 90 days or less and the required notice was given prior to the extension. 3. You obtained replacement coverage or agreed, in writing, within 60 days of the termination of the policy, to obtain that coverage. 4. The policy is for a period of no more than 60 days and you were notified at the time of issuance that it may not be renewed. 5. You requested a change in the terms or conditions or risks covered by the policy within 60 days prior to the end of the policy period. 6. We made a written offer to the insured to renew the policy at a premium rate increase of less than 25 percent. WC61689A COUNTERSIGNED BY ___________________________ (ED. 04-96) AUTHORIZED REPRESENTATIVE INSURED'S COPY NOTICE TO POLICYHOLDER CALIFORNIA WORKERS' COMPENSATION INSURANCE RATING LAWS This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12: 01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-45 Issued to OUTSOURCE INTERNATIONAL, INC. (A CORP.) By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA Pursuant to Section 11752.8 of the California Insurance Code, we are providing you with an explanation of the California workers' compensation rating laws applicable to new and renewal policies with anniversary rating dates on and after January 1, 1995. 1. The laws requiring all insurers to charge the same minimum rate uniformly to all employers within a given classification has been repealed. Beginning January 1, 1995, we will establish our own rates for workers' compensation. Our rates will not be applicable prior to the first normal anniversary rating date of a policy incepting on or after January 1, 1995. Our rates, rating plans and related information are filed with the Insurance Commissioner and are open for public inspection. 2. The Insurance Commissioner can disapprove our rates, rating plans or classifications only if he has determined after public hearing that our rates might jeopardize our ability to pay claims or create a monopoly in the market. A monopoly is defined by law as a market where one insurer writes 20% or more of that part of the California workers' compensation insurance that is not written by the State Compensation Insurance Fund. If the Insurance Commissioner disapproves our rates, rating plans or classifications, he may order an increase in the rates applicable to outstanding Policies. 3. Rating organizations may develop pure premium rates which are subject to the Insurance Commissioner's approval. A pure premium rate reflects the anticipated cost and expenses of claims per $100 of payroll for a given classification. Pure premium rates are advisory only, as we are not required to use the pure premium rates developed by any rating organization in establishing our own rates. 4. We must adhere to a single, uniform experience rating plan. If you are eligible for experience rating under the plan, we will be required to adjust your premium to reflect your claim history. A better claim history generally results in a lower experience rating B modification; more claims, or more expensive claims, generally result in a higher experience rating modification. The uniform experience rating plan developed by the insurance rating organization designated by the Insurance Commissioner is subject to the approval of the Insurance Commissioner. 5. A standard classification system developed by the insurance rating organization designated by the Insurance Commissioner is subject to approval of the Insurance Commissioner. The standard classification system is a method of recognizing and separating policyholders into industry or occupational groups according to their similarities and/or differences. We can adopt and apply the standard classification system or develop and apply our own classification system, provided that we can report the payroll, expenses and other costs of claims in a way which is consistent with the standard classification system. 6. Our rates and classifications may not violate the Unruh Civil Rights Act or be unfairly discriminatory. 7. We will provide an appeal process for you to appeal the way we rate your insurance policy. The process will require us to respond to your written appeal within 30 days. If you are not satisfied with the result of your appeal, you may appeal our decision to the Insurance Commissioner. WC61690 COUNTERSIGNED BY ___________________________ (ED. 01-95) AUTHORIZED REPRESENTATIVE INSURED'S COPY NOTICE TO POLICYHOLDER CALIFORNIA WORKERS' COMPENSATION INSURANCE RATING LAWS This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-45 Issued to OUTSOURCE INTERNATIONAL, INC. (A CORP.) By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA Pursuant to Section 11752.8 of the California Insurance Code, we are informing you of the following changes in laws affecting workers' compensation insurance rating enacted during the 1993 session of the California Legislature: CHANGES EFFECTIVE ON OR BEFORE JANUARY 1, 1994 1. You must notify us if you know facts that prove any aspect of an employee's claim is false. You have the right to dispute whether a claim is compensable. If you dispute claim compensability and you notify us and the Workers' Compensation Appeals Board (WCAB) in writing, and if the WCAB determines that claim noncompensable, you may be entitled to reimbursement of premium you paid due to the inclusion of that claim in your experience modification. 2. When a claim is made, we set a "case reserve" which includes our estimates of medical-legal costs, vocational rehabilitation costs, and all other estimated expenses and benefits to be paid on that claim. At your request, we will provide you a written justification for any case reserve that affects your premium. 3. At your request, we will provide you with all parts of a claim file that affect your premium, and we will discuss the file with you. We cannot provide you, however, with documents that are protected by legal privilege (such as attorney-client privilege) or any documents we are prohibited by law from disclosing. 4. We cannot surcharge your policy by applying a plan or method that is unfairly discriminatory. Prior to January 1, 1995, we will report annually all surcharge plans or methods we use to the Insurance Commissioner. 5. California Insurance code Section 676.8, which specifies the reasons for which we may cancel your policy, provides as follows: 676.8 a) This section applies only to policies of workers' compensation insurance. b) After a policy is in effect, no notice of cancellation shall be effective, unless it complies with the notice requirements for this section and is based upon the occurrence, after the effective date of the policy, of one or more of the following: 1) The policyholder's failure to make any workers' compensation insurance premium payment when due. 2) The policyholder's failure to report payroll, to permit the insurer to audit payroll as required by the terms of the policy or of a previous policy issued by the insurer, or to pay any additional premium as a result of a audit of payroll as required by the terms of the policy or of a previous policy. 3) The policyholder's material failure to comply with federal or state safety orders or written recommendations of the insurer's designated loss control representative. WC61691 (ED. 01-95) 1 of 4 INSURED'S COPY 4) A material change in ownership or any change in the policyholder's business or operations that materially increases the hazard for frequency or severity of loss, requires additional or different classifications for premium calculations, or contemplates an activity excluded by the insurer's reinsurance treaties. 5) Material misrepresentation by the policyholder or its agent. 6) Failure to cooperate with the insurer in the insurer's investigation of a claim. c) A policy shall not be canceled for the conditions specified in paragraph (1), (2), (5), or (6) of subdivision (b) except upon 10 days' written notice to the policyholder by the insurer. A policy shall not be canceled for the conditions specified in paragraph (3) or (4) of subdivision (b) except upon 30 days' written notice to the policyholder by the insurer, provided that no notice is required if an insured and insurer consent to the cancellation and reissuance of a policy effective upon a material change in ownership or operations of the insured. If the policyholder remedies the condition to the insurer's satisfaction within the specified time period, the policy shall not be canceled by the insurer. d) Nothing in this section shall preclude, while policies are in force, changes in the premium rate required or authorized by law, regulation, or order of the Commissioner, or otherwise agreed to between the policyholder and insurer. e) Any policy written for a term longer than one year, or any policy with no fixed expiration date, shall be considered as if written for successive policy periods of one year. CHANGES EFFECTIVE JANUARY 1, 1995 1. The laws requiring all insurers to charge the same minimum rate uniformly to all employers within a given classification has been repealed. Beginning January 1, 1995, we will establish our own rates for workers' compensation. We will file our rates, rating plans and related information with the Insurance Commissioner. The rate information we file will be open for public inspection. 2. The Insurance Commissioner can disapprove our rates, rating plans or classifications only when he has reason to believe that our rates might jeopardize our ability to pay claims or create a monopoly in the market. A monopoly is defined by law as a market where one insurer writes 20% or more of that part of the California workers' compensation insurance that is not written by the State Compensation Insurance Fund. 3. Rating organizations may develop pure premium rates which are subject to the Insurance Commissioner's approval. A pure premium rate reflects the anticipated cost and expenses of claims per $100 of payroll for a given classification. Pure premium rates are advisory only, as we are not required to use the pure premium rates developed by any rating organization in establishing our own rates. 4. All insurers must adhere to a single, uniform experience rating plan. If you are eligible for experience rating under the plan, we will be required to adjust your premium to reflect your claim history. A better claim history generally results in a lower experience rating modification; more claims, or more expensive claims, generally result in a higher experience rating modification. The uniform experience rating plan will be filed with the Insurance Commissioner. 5. The Insurance Commissioner, in conjuction with an insurance rating organization the Insurance Commissioner designates, will develop a classification system, which is a method of recognizing and separating policyholders into industry or occupational groups according to their similarities and/or differences. We can develop a classification system, which is a method of recognizing and separating policyholders into industry or occupational groups according to their similarities and/or differences. We can develop and apply our own classification system, provided that we can report the payroll, expenses and other costs of claims in a way which is consistent with the Insurance Commissioner's designated classification system or uniform statistical plan. 6. Our rates and classifications may not violate the Unruh Civil Rights Act, which shall include any arbitrary economic discrimination as a prohibited basis of discrimination. WC61691 (ED. 01-95) 2 of 4 INSURED'S COPY 7. We will provide an appeal process for you to appeal the way we rate your insurance policy. The process will require us to respond to your written appeal within 30 days. If you are not satisfied with the result of your appeal, you may appeal our decision to the Insurance Commissioner. Section 11752.6 of the California Insurance Code provides that you have the right to the following: 1. RATING INFORMATION. Upon written request, you are entitled to information relating to loss experience, claims, classification assignments and policy contracts as well as rating plans, rating systems, manual rules or other information that impact your premium that is maintained in the records of the Workers' Compensation Insurance Rating Bureau of California ("WCIRB"), a rating organization licensed by the California Insurance Commissioner. 2. POLICYHOLDER OMBUDSPERSON. A policyholder ombudsperson is available to the WCIRB to assist you in obtaining and evaluating the information referenced above. The ombudsperson may represent you in any dispute with us or on appeal to the Insurance Commissioner pursuant to Section 11752.6 of the Insurance Code (copy attached). The address of the WCIRB is One Market, Spear Street Tower, Suite 500, San Francisco, California 94105-1088. The telephone number is (415) 777-0777. 3. STATISTICAL REPORTING. For claims covered under this policy, we will estimate the ultimate cost of unsettled claims for statistical purposes eighteen months after the policy becomes effective and will report those estimates to the WCIRB no later than the twentieth month after the effective date of the policy. The cost of any settled claims will also be reported at that time. At twelve-month intervals thereafter, we will update and report to the WCIRB the estimated cost of any unsettled claims and the actual final cost of any claims settled in the interim. The amounts we report will be used by the WCIRB to compute your experience modification if you are eligible for experience rating. 4. DIVIDEND CALCULATION If this is a participating policy (a policy on which a dividend may be paid), upon payment or non-payment of a dividend, we shall provide a written explanation to you which sets forth the basis of the dividend calculation. The explanation will be in clear, understandable language and will express the dividend as a dollar amount and as a percentage of the earned premium for the policy year on which the dividend is calculated. CALIFORNIA INSURANCE CODE (Policyholder Information Available to Employer) 11752.6 a) A licensed rating organization shall make available, in writing, to an employer insured under a workers' compensation policy, all policyholder information contained in its records upon request of the employer and after notice to the employer's insurer. b) AS used in the section, "policyholder information" means all information relating to the employer's loss experience, claims, classification assignments, and policy contracts, and includes information relating to rating plans, rating systems, manual rules, and any other information that impact the policyholder's pure premium rates. c) If the licensed rating organization rejects an employer's request for that information, the rating organization shall notify the employer in writing as to the reasons for the rejection. An employer whose request for that information has been rejected in whole or in part may appeal to the commissioner in accordance with Section 11753.1. If the commissioner finds that the reasons for the rejection are not justified, he or she may order the rating organization to furnish that information to the employer. d) No licensed rating organization or member thereof, or member of a committee of a licensed rating organization when acting in its capacity as a member of the committee, or officer or employee of a licensed rating organization, when acting within the scope of his or her employment, shall be liable to any person for injury, personal or otherwise, or damages caused or alleged to have been caused, either directly or indirectly, by the disclosure of information to an employer pursuant to this section or for the accuracy or completeness of the Information so disclosed. WC61691 (ED. 01-95) 3 of 4 INSURED'S COPY e) This section shall not be construed as implying the existence of liability in circumstances not defined in this section, nor does it imply a legislative recognition that, except for enactment of this section, a liability has existed or would exist in the circumstances stated in this section. f) This section shall not be construed as limiting any authority of a licensed rating organization to disclose information contained in its records to others. g) There shall be established in all licensed rating organizations a policyholder ombudsman. The policyholder ombudsman shall be a person with sufficient knowledge of the workers' compensation ratemaking process to provide information and assistance to policyholders in obtaining and evaluating the information provided in this section. Every rating organization licensed in this state shall provide staff and other necessary resources to allow the ombudsman to provide prompt and complete service to workers' compensation policyholders of this state. The policyholder ombudsman may represent the policyholder in any dispute with insurers or on appeal to the commissioner as provided in this section. h) For all policies of insurance issued or renewed on or after January 1, 1994, the insurer shall advise the policholder in writing of the following: 1. The policyholder's right to request a written report containing the information set forth in this section from the licensed rating organization of which the insurer is a member and a statement that the policyholder may contact the policyholder ombudsman to assist in obtaining and evaluating that information, together with the telephone number and address of the ombudsman. 2. If a participating policy, that upon payment or nonpayment of a dividend the policyholder shall be provided a written explanation, in a clear and understandable language, setting forth the basis of the calculating and expressing any dividend in both dollar amount and as a percentage of earned premium under the policy. 3. The date when the insurer is required to file the first unit statistical report with the licensed rating organization designated by the commissioner. WC61691 COUNTERSIGNED BY _____________________________ (ED. 01-95) AUTHORIZED REPRESENTATIVE 4 of 4 INSURED'S COPY PAGE 001 ENDORSEMENT # 00001 This endorsement, effective 12:01 AM 01/01/97 Forms a part OF policy no.: RM WC 217-79-45 Issued to: OUTSOURCE INTERNATIONAL, INC. (A CORP.) By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA NAMED INSUREDS FEIN -------------- ---- 00001 OUTSOURCE INTERNATIONAL, INC. (A CORP.) 568842988 00002 LABOR WORLD OF AMERICA, INC. (A CORP.) 592754571 ---------------------------- AUTHORIZED REPRESENTATIVE Issue Date: 04/10/97 IwOOO3 INSURED'S COPY PAGE 001 ENDORSEMENT # 00002 This endorsement, effective 12:01 AM 0 1/01/97 Forms a part of policy no.: RM WC 217-79-45 Issued to: OUTSOURCE INTERNATIONAL, INC. (A CORP.) By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA ADDITIONAL LOCATIONS -------------------- 00001 8000 N FEDERAL HIGHWAY BOCA RATON FL 33487 00002 NO PHYSICAL LOCATION CA 00003 2413 SOUTH GARFIELD AVENUE MONTEREY PARK CA 91754 ----------------------------- AUTHORIZED REPRESENTATIVE Issue Date: 04/10/97 1WO004 INSURED'S COPY ENDORSEMENT # 00003 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-45 Issued to: OUTSOURCE INTERNATIONAL, INC. (A CORP.) BY: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA NOTICE OF CANCELLATION IT IS AGREED THAT IN THE EVENT OF CANCELLATION OF THIS POLICY, THE COMPANY WILL GIVE TO THE NAMED INSURED AT THE ADDRESS INDICATED IN THE DECLARATIONS NINETY (90) DAYS WRITTEN NOTICE OF SUCH CANCELLATION, EXCEPT FOR NONPAYMENT OF PREMIUM WHEREIN ONLY TEN (10) DAYS WILL BE GIVEN. ----------------------------- AUTHORIZED REPRESENTATIVE Issue Date: 04/10/97 1WO014 INSURED'S COPY ENDORSEMENT This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-45 Issued to: OUTSOURCE INTERNATIONAL, INC. (A CORP.) By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA THIS POLICY PROVIDES NO COVERAGE IN THE STATE OF MAINE. ----------------------------- AUTHORIZED REPRESENTATIVE Issue Date: 04/10/97 wc880001 INSURED'S COPY ISSUED BY THE STOCK INSURANCE COMPANY HEREIN CALLED THE COMPANY AGENT NUMBER POLICY NUMBER THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA 13889 84324 RM WC 217-79-45 INCORPORATED UNDER THE LAWS OF PENNSYLVANIA ITEM 1. NAMED INSURED: MAILING ADDRESS IDENTIFICATION NO. SEE ENDT LW0003 OUTSOURCE INTERNATIONAL, INC. (A CORP.) [LOGO] Member Companies of 8000 NORTH FEDERAL HIGHWAY American International Group BOCA RATON FL 33487-0000 EXECUTIVE OFFICES: 70 PINE STREET, NEW YORK, N.Y. 10270 I.D.# PRODUCERS NAME & MAILING ADDRESS WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CENTURY FINANCIAL SERVICES INFORMATION PAGE 185 N W SPANISH RIVER BLVD SUITE 170 BOCA RATON FL 33481 - -------------------------------------------------------------------------------- INSURED IS CORPORATION PREVIOUS POLICY NUMBER RM WC 2117624 (RENEWAL) - -------------------------------------------------------------------------------- OTHER WORKPLACES NOT SHOWN ABOVE SEE ENDT. LW0004 - -------------------------------------------------------------------------------- ITEM 2 POLICY PERIOD 12:01 A.M. STANDARD TIME AT THE INSURED'S MAILING ADDRESS FROM 01/01/97 TO 01/01/98 - -------------------------------------------------------------------------------- ITEM 3 A. WORKERS COMPENSATION INSURANCE: PART ONE OF THE POLICY APPLIES TO WORKERS COMPENSATION LAW OF THE STATES LISTED HERE: CA ------------------------------------------------------------------------- B. EMPLOYERS LIABILITY INSURANCE: PART TWO OF THE POLICY APPLIES TO THE WORK IN EACH STATE LISTED IN ITEM 3.A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE: BODILY INJURY BY ACCIDENT $1,000,000 EACH ACCIDENT BODILY INJURY BY DISEASE $1,000,000 POLICY LIMIT BODILY INJURY BY DISEASE $1,000,000 EACH EMPLOYEE ------------------------------------------------------------------------- C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO THE STATES, IF ANY, LISTED HERE: NONE - -------------------------------------------------------------------------------- ITEM 4 THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, CLASSIFICATIONS, RATES AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. ------------------------------------------------------------------------- ESTIMATED TOTAL RATE PER ESTIMATED CLASSIFICATIONS CODE NUMBER REMUNERATION $100 OF RE- PREMIUM [X]ANNUAL [ ]3 YEAR MUNERATION [X]ANNUAL [ ]3 YEAR - -------------------------------------------------------------------------------- SEE ATTACHED SCHEDULES SURCHARGES / INSURANCE GUARANTEE FUND S/C $3,800 - -------------------------------------------------------------------------------- EXPENSE CONSTANT (EXCEPT WHERE APPLICABLE BY STATE) $160 CA - -------------------------------------------------------------------------------- MINIMUM PREMIUM $750 CA TOTAL ESTIMATED PREMIUM $291,014 - -------------------------------------------------------------------------------- Indicated below, interim adjustments of premium shall be made: [ ]Semi-Annually [ ]Quarterly [ ]Monthly DEPOSIT PREMIUM $ 291,014 - -------------------------------------------------------------------------------- ENDORSEMENTS (FORM NUMBER) SEE ATTACHED SCHEDULE - -------------------------------------------------------------------------------- 04/10/97 ATLANTA 07 - ------------------------------------------------- ISSUE DATE PRINT DATE: 04/11/97 ISSUING OFFICE ---------------------------------------- 39967 AUTHORIZED REPRESENTATIVE WC 00 00 INSURED'S COPY FORMS SCHEDULE Policy Number: RM WC 217-79-45 Effective Date: 01/01/97 - -------------------------------------------------------------------------------- WC000000A TERMS & CONDITIONS 53820 LARGE RISK RATING PLAN ENDT WC000101A DEFENSE BASE ACT COVERAGE ENDT 55154WC CA FRAUD ASSESSMENT WC040002A ADMIN. REVOL. FUND ASSESSMENT WC040101 L & HW COMP ACT COVERAGE-CA WC040301A POLICY AMENDATORY ENDORSEMENT WC040305 VOL COMP & EL COVERAGE ENDT WC040360 CA EL COVERAGE AMEND END WC040401 ANNIVERSARY RATING DATE-CA WC040402 MANDATORY RATE CHANGE ENDT WC040601A CALIFONRIA CANCELLATION ENDT WC61689A NOTICE OF NONRENEWAL WC61690 CA NOT POLICYHOLDER RATING LAW WC61691 CA NOT POLICYHOLDER RATING LAW WC880001 ST OF ME EXCL LW0418 (ED. 1-92) INSURED'S COPY WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY National Union Fire Insurance Company of Pittsburgh, Pa. [LOGO] American Home Assurance Company Member Companies of American International Group, Inc. The Insurance Company of EXECUTIVE OFFICES The State of Pennsylvania 70 PINE STREET NEW YORK, N.Y. 10270 Birmingham Fire Insurance Company of Pennsylvania Commerce and Industry Insurance Company Coverage is provided by the Company designated on the Information Page A Stock Insurance Company WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY QUICK REFERENCE BEGINNING ON PAGE Information Page..........................................................i GENERAL SECTION...........................................................1 A. The Policy........................................................1 B. Who Is Insured....................................................1 C. Workers Compensation Law..........................................1 D. State.............................................................1 E. Locations.........................................................1 PART ONE-WORKERS COMPENSATION INSURANCE...................................1 A. How This Insurance Applies........................................1 B. We Will Pay.......................................................1 C. We Will Defend....................................................1 D. We Will Also Pay..................................................1 E. Other Insurance...................................................2 F. Payments You Must Make............................................2 G. Recovery From Others..............................................2 H. Statutory Provisions..............................................2 THESE POLICY PROVISIONS WITH THE INFORMATION PAGE AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THIS POLICY. "INCLUDES COPYRIGHT MATERIAL OF THE NATIONAL COUNCIL ON COMPENSATION INSURANCE, USED WITH ITS PERMISSION. COPYRIGHT 1983 NATIONAL COUNCIL ON COMPENSATION INSURANCE" 39638C(04/92) WC 00 00 00 A (STANDARD) INSURED'S COPY ED 4 92 QUICK REFERENCE - CONTINUED BEGINNING ON PAGE PART TWO - EMPLOYERS LIABILITY INSURANCE ............................. 2 A. How This Insurance Applies ............................... 2 B. We Will Pay .............................................. 3 C. Exclusions ............................................... 3 D. We Will Defend ........................................... 3 E. We Will Also Pay ......................................... 4 F. Other Insurance .......................................... 4 G. Limits of Liability ...................................... 4 H. Recovery From Others ..................................... 4 I. Action Against Us ........................................ 4 PART THREE - OTHER STATES INSURANCE .................................. 4 A. How This Insurance Applies ............................... 4 B. Notice ................................................... 5 PART FOUR - YOUR DUTIES IF INJURY OCCURS ............................. 5 PART FIVE - PREMIUM .................................................. 5 A. Our Manuals .............................................. 5 B. Classifications .......................................... 5 C. Remuneration ............................................. 5 D. Premium Payments ......................................... 5 E. Final Premium ............................................ 5 F. Records .................................................. 6 G. Audit .................................................... 6 PART SIX - CONDITIONS ................................................ 6 A. Inspection ............................................... 6 B. Long Term Policy ......................................... 6 C. Transfer of Your Rights and Duties........................ 6 D. Cancellation ............................................. 6 E. Sole Representative ...................................... 6 IMPORTANT: This Quick Reference is not part of the Workers Compensation and Employers Liability Policy and does not provide coverage. Refer to the Workers Compensation and Employers Liability Policy itself for actual contractual provisions. PLEASE READ THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CAREFULLY INSURED'S COPY ATTACH FORM AND ENDORSEMENTS (IF ANY) HERE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to all terms of this policy, WE agree with you as follows. GENERAL SECTION A. THE POLICY This policy includes at its effective date the Information Page and all endorsements and schedules listed there. It is a contract of insurance between you (the employer named in Item 1 of the Information Page) and us (the insurer named on the Information Page). The only agreements relating to the insurance are stated in this policy. The terms of this policy may not be changed or waived except by endorsement issued by us to be part of this policy. B. WHO IS INSURED You are insured if you are an employer named in Item 1 of the Information Page. If that employer is a partnership, and if you are one of its partners, you are insured, but only in your capacity as an employer of the partnership's employees. C. WORKERS COMPENSATION LAW Workers Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page. It includes any amendments to that law which are in effect during the policy period. It does not include any federal workers or workmen's compensation law, any federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. D. STATE State means any state of the United States of America, and the District of Columbia. E. LOCATIONS This policy covers all of your workplaces listed in Items 1 or 4 of the Information Page; and it covers all other workplaces in Item 3.A states unless you have other insurance or are self-insured for such workplaces. PART ONE - WORKERS COMPENSATION INSURANCE A. HOW THIS INSURANCE APPLIES This workers compensation insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. Bodily injury by accident must occur during the policy period. 2. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. B. WE WILL PAY We will pay promptly when due the benefits required of you by the workers compensation law. C. WE WILL DEFEND We have the right and duty to defend at our expense any claim, proceeding or suit against you for benefits payable by this insurance. We have the right to investigate and settle these claims, proceedings or suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. D. WE WILL ALSO PAY We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding or suit we defend: 1. reasonable expenses incurred at our request, but not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amount payable under this insurance; WC 00 00 00 A 1 of 7 INSURED'S COPY 3. litigation costs taxed against you; 4. interest on a judgment as required by law until we offer the amount due under this insurance; and 5. expenses we incur. E. OTHERINSURANCE We will not pay more than our share of benefits and costs covered by this insurance and other insurance or self-insurance. Subject to any limits of liability that may apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance will be equal until the loss is paid. F. PAYMENTS YOU MUST MAKE You are responsible for any payments in excess of the benefits regularly provided by the workers compensation law including those required because: 1. of your serious and willful misconduct; 2. you knowingly employ an employee in violation of law; 3. you fail to comply with a health or safety law or regulation; or 4. you discharge, coerce or otherwise discriminate against any employee in violation of the workers compensation law. If we make any payments in excess of the benefits regularly provided by the workers compensation law on your behalf, you will reimburse us promptly. G. RECOVERY FROM OTHERS We have your rights, and the rights of persons entitled to the benefits of this insurance, to recover our payments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. H. STATUTORY PROVISIONS These statements apply where they are required by law. 1. As between an injured worker and us, we have notice of the injury when you have notice. 2. Your default or the bankruptcy or insolvency of you or your estate will not relieve us of our duties under this insurance after an injury occurs. 3. We are directly and primarily liable to any person entitled to the benefits payable by this insurance. Those persons may enforce our duties; so may an agency authorized by law. Enforcement may be against us or against you and us. 4. Jurisdiction over you is jurisdiction over us for purposes of the workers compensation law. We are bound by decisions against you under that law, subject to the provisions of this policy that are not in conflict with that law. 5. This insurance conforms to the parts of the workers compensation law that apply to: a. benefits payable by this insurance or; b. special taxes, payments into security or other special funds, and assessments payable by us under that law. 6. Terms of this insurance that conflict with the workers compensation law are changed by this statement to conform to that law. Nothing in these paragraphs relieves you of your duties under this policy. PART TWO - EMPLOYERS LIABILITY INSURANCE A. HOW THIS INSURANCE APPLIES This employers liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must arise out of and in the course of the injured employee's employment by you. 2. The employment must be necessary or incidental to your work in a state or territory listed in Item 3.A. of the Information Page. 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. If you are sued, the original suit and any related legal actions for damages for bodily injury WC 00 00 00 A 2 of 7 INSURED'S COPY by accident or by disease must be brought in the United States of America, its territories or possessions, or Canada. B. WE WILL PAY We will pay all sums you legally must pay as damages because of bodily injury to your employees, provided the bodily injury is covered by this Employers Liability Insurance. The damages we will pay, where recovery is permitted by law, include damages: 1. for which you are liable to a third party by reason of a claim or suit against you by that third party to recover the damages claimed against such third party as a result of injury to your employee; 2. for care and loss of services; and 3. for consequential bodily injury to a spouse, child, parent, brother or sister of the injured employee; provided that these damages are the direct consequence of bodily injury that arises out of and in the course of the injured employee's employment by you; and 4. because of bodily injury to your employee that arises out of and in the course of employment, claimed against you in a capacity other than as employer. C. EXCLUSIONS This insurance does not cover: 1. liability assumed under a contract. This exclusion does not apply to a warranty that your work will be done in a workmanlike manner; 2. punitive or exemplary damages because of bodily injury to an employee employed in violation of law; 3. bodily injury to an employee while employed in violation of law with your actual knowledge or the actual knowledge of any of your executive officers; 4. any obligation imposed by a workers compensation, occupational disease, unemployment compensation, or disability benefits law, OR any similar law; 5. bodily injury intentionally caused or aggravated by you; 6. bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America or Canada who is temporarily outside these countries; 7. damages arising out of coercion, criticism, demotion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimination against or termination of any employee, or any personnel practices, policies, acts or omissions. 8. bodily injury to any person in work subject to the Longshore and Harbor Workers' Compensation Act (33 USC Sections 901-950), the Nonappropriated Fund Instrumentalities Act (5 USC Sections 8171-8173), the Outer Continental Shelf Lands Act (43 USC Sections 1331-1356), the Defense Base Act (42 USC Sections 1651-1654), the Federal Coal Mine Health and Safety Act of 1969 (30 USC Sections 901-942), any other federal workers or workmen's compensation law or other federal occupational disease law, or any amendments to these laws. 9. bodily injury to any person in work subject to the Federal Employers' Liability Act (45 USC Sections 51-60), any other federal laws obligating an employer to pay damages to an employee due to bodily injury arising out of or in the course of employment, or any amendments to those laws. 10. bodily injury to a master or member of the crew of any vessel. 11. fines or penalties imposed for violation of federal or state law. 12. damages payable under the Migrant and Seasonal Agricultural Worker Protection Act (29 USC Sections 1801-1872) and under any other federal law awarding damages for violation of those laws or regulations issued thereunder, and any amendments to those laws. D. WE WILL DEFEND We have the right and duty to defend, at our expense, any claim, proceeding or suit against you for damages payable by this insurance. We have the right to investigate and settle these claims, proceedings and suits. WC 00 00 00 A 3 of 7 INSURED'S COPY We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. We have no duty to defend or continue defending after we have paid our applicable limit of liability under this insurance. E. WE WILL ALSO PAY We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim proceeding, or suit we defend; 1. reasonable expenses incurred at our request; but not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the limit of our liability under this insurance; 3. litigation costs taxed against you; 4. interest on a judgment as required by law until we offer the amount due under this insurance; and 5. expenses we incur. F. OTHER INSURANCE We will not pay more than our share of damages and costs covered by this insurance and other insurance or self-insurance. Subject to any limits of liability that apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance and self-insurance will be equal until the loss is paid. G. LIMITS OF LIABILITY Our liability to pay for damages is limited. Our limits of liability are shown in Item 3.B. of the Information Page. They apply as explained below. 1. Bodily Injury by Accident. The limit shown for "bodily injury by accident-each accident" is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident. A disease is not bodily injury by accident unless it results directly from bodily injury by accident. 2. Bodily Injury by Disease. The limit shown for "bodily injury by disease-policy limit" is the most we will pay for all damages covered by this insurance and arising out of bodily injury by disease, regardless of the number of employees who sustain bodily injury by disease. The limit shown for "bodily injury by disease each employee" is the most we will pay for all damages because of bodily injury by disease to any one employee. Bodily injury by disease does not include disease that results directly from a bodily injury by accident. 3. We will not pay any claims for damages after we have paid the applicable limit of our liability under this insurance. H. RECOVERY FROM OTHERS We have your rights to recover our payment from anyone liable for an injury covered by this insurance. You will do everything necessary to protect those rights for us and to help us enforce them. I. ACTIONS AGAINST US There will be no right of action against us under this insurance unless: 1. You have complied with all the terms of this policy; and 2. The amount you owe has been determined with our consent or by actual trial and final judgment. This insurance does not give anyone the right to add us as a defendant in an action against you to determine your liability. The bankruptcy or insolvency of you or your estate will not relieve us of our obligations under this Part. PART THREE - OTHER STATES INSURANCE A. HOW THIS INSURANCE APPLIES 1. This other states insurance applies only if one or more states are shown in Item 3-C. of the Information Page. 2. If you begin work in any one of those states after the effective date of this policy and are not insured or are not self-insured for such work, all provisions of the policy will apply as though that state were listed in Item 3.A. of the Information Page. 3. We will reimburse you for the benefits required by the workers compensation law of that state if we are not permitted to pay the benefits directly to persons entitled to them. 4. If you have work on the effective date of this policy in any state not listed in Item 3.A. of the WC 00 00 00 A 4 of 7 INSURED'S COPY Information Page, coverage will not be afforded for that state unless we are notified within thirty days. B. NOTICE Tell us at once if you begin work in any state listed in Item 3.C. of the Information Page. PART FOUR - YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered by this policy. Your other duties are listed here. 1. Provide for immediate medical and other services required by the workers compensation law. 2. Give us or our agent the names and addresses of the injured persons and of witnesses, and other information we may need. 3. Promptly give us all notices, demands and legal papers related to the injury, claim, proceeding or suit. 4. Cooperate with us and assist us, as we may request, in the investigation, settlement or defense of any claim, proceeding or suit. 5. Do nothing after an injury occurs that would interfere with our right to recover from others. 6. Do not voluntarily make payments, assume obligations or incur expenses, except at your own cost. PART V -PREMIUM A. Our MANUALS All premium for this policy will be determined by our manuals of rules, rates, rating plans and classifications. We may change our manuals and apply the changes to this policy if authorized by law or a governmental agency regulating this insurance. B. CLASSIFICATIONS Item 4 of the Information Page shows the rate and premium basis for certain business or work classifications. These classifications were assigned based on an estimate of the exposures you would have during the policy period. If your actual exposures are not properly described by those classifications, we will assign proper classifications, rates and premium basis by endorsement to this policy. C. REMUNERATION Premium for each work classification is determined by multiplying a rate times a premium basis. Remuneration is the most common premium basis. This premium basis includes payroll and all other remuneration paid or payable during the policy period for the services of: 1. All your officers and employees engaged in work covered by this policy; and 2. All other persons engaged in work that could make us liable under Part One (Workers Compensation Insurance) of this policy. If you do not have payroll records for these persons, the contract price for their services and materials may be used as the premium basis. This paragraph 2 will not apply if you give us proof that the employers of these persons lawfully secured their workers compensation obligations. D. PREMIUM PAYMENTS You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. E. FINAL PREMIUM The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the balance. If it is less, we will refund the balance to you. The final premium will not be less than the highest minimum premium for the classifications covered by this policy. If this policy is canceled, final premium will be determined in the following way unless our manuals provide otherwise. 1. If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. 2. If you cancel, final premium will be more than pro rata; it will be based on the time this policy was in force, and increased by our short rate WC 00 00 00 A 5 of 7 INSURED'S COPY cancellation table and procedure. Final premium will not be less than the minimum premium. F. RECORDS You will keep records of information needed to compute premium. You will provide us with copies of those records when we ask for them. G. AUDIT You will let us examine and audit all your records that relate to this policy. These records include ledgers, journals, registers, vouchers, contracts, tax reports, payroll and disbursement records, and programs for storing and retrieving data. We may conduct the audits during regular business hours during the policy period and within three years after the policy period ends. Information developed by audit will be used to determine final premium. Insurance rate service organizations have the same rights we have under this provision. PART SIX - CONDITIONS A. INSPECTION We have the right, but are not obliged to inspect your workplaces at any time. Our inspections are not safety inspections. They relate only to the insurability of the workplaces and the premiums to be charged. We may give you reports on the conditions we find. We may also recommend changes. While they may help reduce losses, we do not undertake to perform the duty of any person to provide for the health or safety of your employees or the public. We do not warrant that your workplaces are safe or healthful or that they comply with laws, regulations, codes or standards. Insurance rate service organizations have the same rights we have under this provision. B. LONG TERM POLICY If the policy period is longer than one year and sixteen days, all provisions of this policy will apply as though a new policy were issued on each annual anniversary that this policy is in force. C. TRANSFER OF YOUR RIGHTS AND DUTIES Your rights or duties under this policy may not be transferred without our written consent. If you die and we receive notice within thirty days after your death, we will cover your legal representative as insured. D. CANCELLATION 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancellation is to take effect. 2. We may cancel this policy. We must mail or deliver to you not less than ten days advance written notice stating when the cancellation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 3. The policy period will end on the day and hour stated in the cancellation notice. 4. Any of these provisions that conflicts with a law that controls the cancellation of the insurance in this policy is changed by this statement to comply with that law. E. SOLE REPRESENTATIVE The insured first named in Item 1 of the Information Page will act on behalf of all insureds to change this policy, receive return premium, and give or receive notice of cancellation. WC 00 00 00 A 6 of 7 INSURED'S COPY In WITNESS WHEREOF, the company has caused this policy to be executed and attested, but this policy shall not be valid unless countersigned by a duly authorized representative of the company. /s/ WILLIAM D. SMITH /s/ [ILLEGIBLE] -------------------- --------------- President President The Insurance Company National Union Fire of The State of Pennsylvania Insurance Company of Birmingham Fire Insurance Pittsburgh, PA Company of Pennsylvania /s/ WALTER L. MOONEY /s/ [ILLEGIBLE] -------------------- --------------- President President Commerce and Industry American Home Insurance Company Assurance Company /s/ ELIZABETH M. TUCK --------------------- Secretary National Union Fire Insurance Company of Pittsburgh, PA American Home Assurance Company The Insurance Company of The State of Pennsylvania Birmingham Fire Insurance Company of Pennsyivania Commerce and Industry Insurance Company WC 00 00 00 A 7 of 7 INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-45 CALIFORNIA - ------------------ ---------- ------------------------------ POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID 317080l ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ----------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ----------------------------------------------------------------------------------------------------------------------- Entries in this item, except as specifically provided elsewhere in this policy, do not modify Code Estimated Total Per $100 of Estimated any of the other provisions of this policy. No. Annual Remuneration Remuneration Annual Premiums OUTSOURCE INTERNATIONAL, INC.(A CORP.) JOB SITE ONLY HOLLYWOOD, CA 90027 NURSERIES--PROPAGATION AND CULTIVATION 0005 6,600 7.60 502 OF NURSERY STOCK LANDSCAPE GARDENING- ALL OPERATIONS 0042 4,900 12.28 602 INCLUDING MAINTENANCE OF GARDENS FARM MACHINERY OPERATION- BY CONTRACTORS 0050 600 10.02 60 INCLUDING YARD EMPLOYEES. IRRIGATION, DRAINAGE OR RECLAMATION 0251 200 5.76 12 ___S OPERATION- ALL WORK INCIDENTAL TO MAINTENANCE AND OPERATION OF IRRIGATION, DRAINAGE OR RECLAMATION DISTRICTS -- N.P.D. WITH "FARMS" GRAIN OR RICE MILLING. 2014 17,200 10.27 1,766 CREAMERIES AND DAIRY PRODUCTS MFG. 2063 1,500 6.34 95 BOTTLING-BEVERAGES-NO SPIRITUOUS 2163 200,900 7.05 14,163 LIQUORS. SPINNING OR WEAVING -- NATURAL AND 2222 900 12.44 112 SYNTHETIC FIBRES N.O.C. TEXTILES-BLEACHING DYEING MERCERIZING 2413 3,900 10.91 425 FINISHING-NEW GOODS-NOT CLEANING AND DYEING OF GARMENTS CLOTHING MFG.-INCLUDING EMBROIDERY 2501 151,900 7.74 11,757 MANUFACTURING CARPET, RUG, OR UPHOLSTERY CLEANING 2584 1,600 12.52 200 - --SHOP OR OUTSIDE--N.P.D. DRY CLEANING OPERATIONS SHALL BE SEPARATELY RATED IN ACCORDANCE WITH THE PROVISIONS OF THIS MANUAL. - ---------------------------------------------------------------------------------------------------------------- WC 7754 (ED. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-45 CALIFORNIA - ------------------ ---------- ------------------------------ POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID 317080l ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ----------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ----------------------------------------------------------------------------------------------------------------------- Entries in this item, except as specifically provided elsewhere in this policy, do not modify Code Estimated Total Per $100 of Estimated any of the other provisions of this policy. No. Annual Remuneration Remuneration Annual Premiums LAUNDRIES-N 0 C-ALL EMPLOYEES-INCLUDING 2585 15,300 7.67 1,174 CASH AND CARRY DEPARTMENTS ON PLANT PREMISES DRY CLEANING OR DYEING N.O.C.-INCLUDING 2586 300 7.16 21 REPAIRING OR PRESSING AND CASH AND CARRY DEPARTMENTS ON PLANT PREMISES 2623 3,600 11.08 399 TANNING PLANING OR MOULDING MILLS 2731 300 9.92 30 PATTERN OR MODEL MFG-METAL, PLASTIC, OR 2790 139,400 4.55 6,343 WOOD. DOOR, SASH OR WINDOW MFG.--WOOD 2806 6,200 11.52 714 ___ NET MFG.--WOOD--INCLUDING THE 2812 1,300 9.78 127 MANUFACTURE OF COMMERCIAL OR INDUSTRIAL FIXTURES WOOD PRODUCTS MFG.--N.O.C. 2842 18,000 10.24 1,843 WINDOW BLIND MFG. OR ASSEMBLY--ALL TYPES 2852 98,600 8.78 8,657 FURNITURE MFG.--WOOD-- 2883 600 14.73 88 INCLUDING ASSEMBLING OR FINISHING. STEEL MAKING 3018 200 4.86 10 DOOR OR WINDOW MFG.-METAL OR COMBINATION 3060 10,100 9.09 918 METAL AND GLASS SHEET METAL PRODUCTS MFG-N.O.C. 3066 352,800 6.62 23,355 TOOL MFG.--N.O.C. 3099 11,700 4.62 541 TOOL MFG.--HOT FORMED TOOLS--INCLUDING 3110 707,800 13.26 93,854 TRIMMING, MACHINING OF PARTS AND DIEMAKING OPERATIONS HEAT TREATING-METAL-N.P.D. 3146 2,700 6.49 175 ____TACK OR RIVER MFG.--COLD OR HOT 3152 28,600 3.93 1,124 - ----------------------------------------------------------------------------------------------------------------- WC 7754 (ED. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-45 CALIFORNIA - ------------------ ---------- ------------------------------ POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID 317080l ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ----------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ----------------------------------------------------------------------------------------------------------------------- Entries in this item, except as specifically provided elsewhere in this policy, do not modify Code Estimated Total Per $100 of Estimated any of the other provisions of this policy. No. Annual Remuneration Remuneration Annual Premiums WORK AIR-CONDITIONING AND REFRIGERATION 3165 2,200 5.06 111 EQUIPMENT MFG FURNACE, HEATER OR RADIATOR MFG 3175 3,000 9.04 271 ELECTRONIC ELEMENT MFG.-N.O.C.- 3178 27,300 3.82 1,043 N.P.D ELECTRICAL APPARATUS MFG.-N.O.C.- 3179 182,000 6.38 11,612 N.P.D. WITH 3643, "ELECTRIC POWER OR TRANSMISSION EQUIPMENT MFG.--N.O.C.", AND 3643,"ELECTRIC CONTROL PANEL OR SWITCHGEAR MFG." FIXTURES OR LAMP MFG OR ASSEMBLY- 3180 293,700 9.26 27,197 _____--ELECTRIC OR GAS WELDING OR CUTTING -- N.O.C. -- SHOP OR 3365 23,400 15.88 3,716 OUTSIDE -- INCLUDING INCIDENTAL MACHINING OPERATIONS CONNECTED THEREWITH -- N.P.D DETINNING 3372 267,200 11.00 29,392 METAL GOODS MFG-N.O.C 3400 131,400 8.42 11,064 MACHINE MFG.-OFFICE OR SEWING-N.O.C 3574 55,200 4.50 2,484 THIS CLASSIFICATION CONTEMPLATES, BUT IS NOT LIMITED TO, THE MANUFACTURE OF OFFICE MACHINES SUCH AS TYPEWRITERS, DUPLICATORS, STAPLERS, LABELERS AND POSTAGE AFFIXERS; SEWING MACHINES; CASH REGISTERS; CARBURETORS; SPEEDOMETERS; SMALL ARMS; AND FILM DEVELOPING EQUIPMENT BATTERY MFG-STORAGE--INCLUDING 3647 82,400 12.55 10,341 FOUNDRY OPERATIONS INSTRUMENT MFG.-PROFESSIONAL OR 3681 31,600 2.21 698 SCIENTIFIC-N.O.C ____WRIGHT WORK - N.O.C. -- ERECTION OR 3724 22,800 9.06 2,066 - -------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-45 CALIFORNIA - ------------------ ---------- ------------------------------ POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID 317080l ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ----------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ----------------------------------------------------------------------------------------------------------------------- Entries in this item, except as specifically provided elsewhere in this policy, do not modify Code Estimated Total Per $100 of Estimated any of the other provisions of this policy. No. Annual Remuneration Remuneration Annual Premiums REPAIR OF MACHINERY OR EQUIPMENT THIS CLASSIFICATION IS NOT AVAILABLE FOR DIVISION OF PAYROLL OF EMPLOYEES OF INSURED ENGAGED IN MILLWRIGHT WORK ON THE PREMISES BOTH OCCUPIED AND OPERATED BY THE INSURED. SUCH PAYROLL SHALL BE INCLUDED IN THE GOVERNING CLASSIFICATION AUTOMOBILE OR AUTOMOBILE TRUCK ENGINE MFG 3805 21,900 3.79 830 AUTOMOBILE OR MOTORCYCLE MFG OR ASSEMBLING 3808 16,000 3.01 482 DREDGING--INCLUDING MAINTENANCE AND 4000 14,000 7.62 1,135 REPAIR OF DREDGING EQUIPMENT ___ AND DELIVERY OPERATIONS PERTAINING ___ THE SALE OF DREDGED MATERIALS SHALL BE SEPARATELY RATED AS 8232, "BUILDING MATERIAL DEALERS" PLASTER BOARD OR PLASTER BLOCK MFG 4036 11,200 5.61 628 GLASSWARE MFG--NO AUTOMATIC OR SEMIAUTOMATIC 4111 9,000 2.73 246 MACHINES 4239 18,300 4.46 816 FIBRE PREPARATION-WOOD 4243 69,400 5.38 3,734 BOX MFG.-FOLDING PAPER BOXES-N.O.C 4244 10,600 7.48 793 CORRUGATED OR FIBRE BOARD CONTAINER MFG- INCLUDING CORRUGATING OR LAMINATING OF PAPER PRINTING OPERATION-ALL OTHER EMPLOYEES- 4299 105,900 5.24 5,549 INCLUDING MISCELLANEOUS EMPLOYEES-N.O.C NEWSPAPER DELIVERY-THIS CLASSIFICATION 4312 200 10.78 22 APPLIES TO PERSONS SELLING OR DELIVERING NEWSPAPERS TO CUSTOMERS, FOR THEIR PERSONAL USE AND NOT FOR RESALE. SUCH PERSONS SHALL BE INCLUDED AT THEIR __UAL RENUMERATION BUT IN NO EVENT FOR - ---------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-45 CALIFORNIA - ------------------ ---------- ------------------------------ POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID 317080l ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ----------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ----------------------------------------------------------------------------------------------------------------------- Entries in this item, except as specifically provided elsewhere in this policy, do not modify Code Estimated Total Per $100 of Estimated any of the other provisions of this policy. No. Annual Remuneration Remuneration Annual Premiums A SUM LESS THAN #2.00 PER PERSON PER DAY NEWSPAPERS ARE SOLD OR DELIVERED. PHOTO ENGRAVING-N P D 4351 3,600 1.61 58 ELECTRONICS INDUSTRY: 4354 600 3.52 21 PRINTED CIRCUIT BOARD MFG.--N.P.D. MOTION PICTURES: DEVELOPMENT OF 4360 25,900 1.57 407 NEGATIVES, PRINTING AND ALL SUBSEQUENT OPERATION EXCEPT THE MARKETING OF THE PRODUCT THROUGH FILM EXCHANGES AT LOCATIONS OTHER THAN THE STUDIO MOTION PICTURES--FILM EXCHANGES--NOT 4362 5,800 2.07 120 LOCATED AT MOTION PICTURE STUDIO-- INCLUDING PROJECTION ROOM; CLERICAL ___CE EMPLOYEES RUBBER TIRE MFG. 4414 537,700 3.56 19,142 PLASTICS--BLOW MOLDED PRODUCTS MFG. 4494 67,200 9.39 6,310 - --N.O.C. PLASTICS--EXTRUSION MOLDED PRODUCTS MFG. 4495 4,000 7.42 297 - --N.O.C. PLASTICS--FABRICATED PRODUCTS MFG.--NO 4496 15,500 7.74 1,200 MOLDING--N.O.C. PLASTICS--INJECTION MOLDED PRODUCTS 4498 380,400 7.34 27,921 MFG.--N.O.C. PLASTICS--THERMOFORMED PRODUCTS MFG.-- 4499 1,500 8.45 127 N.O.C. PAINT, VARNISH OR LACQUER MFG. 4558 4,800 5.30 254 DRUG, MEDICINE OR PHARMACEUTICAL 4611 8,300 4.15 344 PREPARATIONS MFG.-COMPOUNDING, BLENDING OR PACKAGING ONLY-NOT MANUFACTURING INGREDIENTS - N.O.C. ___ER SUBSTITUTES MFG 4717 16,900 5.18 875 - ---------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY ISSUED BY THE STOCK INSURANCE COMPANY HEREIN CALLED THE COMPANY AGENT NUMBER POLICY NUMBER - ------------------------------------- ------------ ------------- THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA 13889 84324 RM WC 217-79-46 INCORPORATED UNDER THE LAWS OF PENNSYLVANIA ITEM 1. NAMED INSURED: MAILING ADDRESS IDENTIFICATION NO. - ------------------------------------------------------------- OUTSOURCE INTERNATIONAL, INC. [LOGO] Member Companies of 8000 NORTH FEDERAL HIGHWAY American International Group BOCA RATON FL 33487-0000 EXECUTIVE OFFICES: 70 PINE STREET, NEW YORK, N.Y. 10270 I.D.# 917-356254 PRODUCERS NAME & MAILING ADDRESS WORKERS COMPENSATION AND -------------------------------- EMPLOYERS LIABILITY POLICY CENTURY FINANCIAL SERVICES INFORMATION PAGE 185 N W SPANISH RIVER BLVD SUITE 170 BOCA RATON FL 33481 - -------------------------------------------------------------------------------- INSURED IS CORPORATION PREVIOUS POLICY NUMBER NEW - -------------------------------------------------------------------------------- OTHER WORKPLACES NOT SHOWN ABOVE - -------------------------------------------------------------------------------- ITEM 2 POLICY PERIOD 12:01 A.M. STANDARD TIME AT THE INSURED'S MAILING ADDRESS FROM 01/01/97 TO 01/01/98 - -------------------------------------------------------------------------------- ITEM 3 A. WORKERS COMPENSATION INSURANCE: PART ONE OF THE POLICY APPLIES TO WORKERS COMPENSATION LAW OF THE STATES LISTED HERE: ID ------------------------------------------------------------------------- B. EMPLOYERS LIABILITY INSURANCE: PART TWO OF THE POLICY APPLIES TO THE WORK IN EACH STATE LISTED IN ITEM 3.A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE: BODILY INJURY BY ACCIDENT $1,000,000 EACH ACCIDENT BODILY INJURY BY DISEASE $1,000,000 POLICY LIMIT BODILY INJURY BY DISEASE $1,000,000 EACH EMPLOYEE ------------------------------------------------------------------------- C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO THE STATES, IF ANY, LISTED HERE: NONE - -------------------------------------------------------------------------------- ITEM 4 THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, CLASSIFICATIONS, RATES AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. ------------------------------------------------------------------------- ESTIMATED TOTAL RATE PER ESTIMATED CLASSIFICATIONS CODE NUMBER REMUNERATION $100 OF RE- PREMIUM [X]ANNUAL [ ]3 YEAR MUNERATION [X]ANNUAL [ ]3 YEAR - -------------------------------------------------------------------------------- SEE ATTACHED SCHEDULES - -------------------------------------------------------------------------------- EXPENSE CONSTANT (EXCEPT WHERE APPLICABLE BY STATE) $0 - -------------------------------------------------------------------------------- MINIMUM PREMIUM $150 ID TOTAL ESTIMATED PREMIUM $150 - -------------------------------------------------------------------------------- Indicated below, interim adjustments of premium shall be made: [ ]Semi-Annually [ ]Quarterly [ ]Monthly DEPOSIT PREMIUM $ 150 - -------------------------------------------------------------------------------- ENDORSEMENTS (FORM NUMBER) SEE ATTACHED SCHEDULE - -------------------------------------------------------------------------------- 04/10/97 ATLANTA 07 - ------------------------------------------------- ISSUE DATE PRINT DATE: 04/11/97 ISSUING OFFICE ---------------------------------------- 39967 AUTHORIZED REPRESENTATIVE WC 00 00 01 INSURED'S COPY FORMS SCHEDULE Policy Number: RM WC 217-79-46 Effective Date: 01/01/97 - -------------------------------------------------------------------------------- WC000000A TERMS & CONDITIONS 53820 LARGE RISK RATING PLAN ENDT WC000101A DEFENSE BASE ACT COVERAGE ENDT WC000106A USL&H WC ACT COVERGE END. WC000301A ALTERNATE EMPLOYER ENDORSEMENT WC000311A VOL COMP & EL COVERAGE ENDT WC000403 EXPERIENCE RATING MOD FACTOR WC000414 NOTIFICATION OF CHG OWNERSHIP WC880001 ST OF ME EXCL LW0418 (ED. 1-92) INSURED'S COPY WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY National Union Fire Insurance Company of Pittsburgh, Pa. [LOGO] American Home Assurance Company Member Companies of American International Group, Inc. The Insurance Company of EXECUTIVE OFFICES The State of Pennsylvania 70 PINE STREET NEW YORK, N.Y. 10270 Birmingham Fire Insurance Company of Pennsylvania Commerce and Industry Insurance Company Coverage is provided by the Company designated on the Information Page A Stock Insurance Company WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY QUICK REFERENCE BEGINNING ON PAGE Information Page..........................................................i GENERAL SECTION...........................................................1 A. The Policy........................................................1 B. Who Is Insured....................................................1 C. Workers Compensation Law..........................................1 D. State.............................................................1 E. Locations.........................................................1 PART ONE-WORKERS COMPENSATION INSURANCE...................................1 A. How This Insurance Applies........................................1 B. We Will Pay.......................................................1 C. We Will Defend....................................................1 D. We Will Also Pay..................................................1 E. Other Insurance...................................................2 F. Payments You Must Make............................................2 G. Recovery From Others..............................................2 H. Statutory Provisions..............................................2 THESE POLICY PROVISIONS WITH THE INFORMATION PAGE AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THIS POLICY. "INCLUDES COPYRIGHT MATERIAL OF THE NATIONAL COUNCIL ON COMPENSATION INSURANCE, USED WITH ITS PERMISSION. COPYRIGHT 1983 NATIONAL COUNCIL ON COMPENSATION INSURANCE" 39638C(04/92) WC 00 00 00 A (STANDARD) INSURED'S COPY ED 4 92 QUICK REFERENCE - CONTINUED BEGINNING ON PAGE PART TWO - EMPLOYERS LIABILITY INSURANCE............................. 2 A. How This Insurance Applies............................... 2 B. We Will Pay.............................................. 3 C. Exclusions............................................... 3 D. We Will Defend........................................... 3 E. We Will Also Pay......................................... 4 F. Other Insurance.......................................... 4 G. Limits of Liability...................................... 4 H. Recovery From Others..................................... 4 L. Action Against Us........................................ 4 PART THREE - OTHER STATES INSURANCE.................................. 4 A. How This Insurance Applies............................... 4 B. Notice................................................... 5 PART FOUR - YOUR DUTIES IF INJURY OCCURS............................. 5 PART FIVE - PREMIUM.................................................. 5 A. Our Manuals.............................................. 5 B. Classifications.......................................... 5 C. Remuneration............................................. 5 D. Premium Payments......................................... 5 E. Final Premium............................................ 5 F. Records.................................................. 6 G. Audit.................................................... 6 PART SIX - CONDITIONS.............................................. 6 A. Inspection............................................... 6 S. Long Term Policy......................................... 6 C. Transfer of Your Rights and Duties....................... 6 D. Cancellation............................................. 6 E. Sole Representative...................................... 6 IMPORTANT: This Quick Reference is not part of the Workers Compensation and Employers Liability Policy and does not provide coverage. Refer to the Workers Compensation and Employers Liability Policy itself for actual contractual provisions. PLEASE READ THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CAREFULLY INSURED'S COPY ATTACH FORM AND ENDORSEMENTS (IF ANY) HERE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows. GENERAL SECTION A. THE POLICY This policy includes at its effective date the Information Page and all endorsements and schedules listed there. It is a contract of insurance between you (the employer named in Item 1 of the Information Page) and us (the insurer named on the Information Page). The only agreements relating to this insurance are stated in this policy. The terms of this policy may not be changed or waived except by endorsement issued by us to be part of this policy. B. WHO IS INSURED You are insured if you are an employer named in Item 1 of the Information Page. If that employer is a partnership, and if you are one of its partners, you are insured, but only in your capacity as an employer of the partnership's employees. C. WORKERS COMPENSATION LAW Workers Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page. It includes any amendments to that law which are in effect during the policy period. It does not include any federal workers or workman's compensation law, any federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. D. STATE State means any state of the United States of America, and the District of Columbia. E. LOCATIONS This policy covers all of your workplaces listed in Items 1 or 4 of the Information Page; and it covers all other workplaces in Item 3.A states unless you have other insurance or are self-insured for such workplaces. PART ONE - WORKERS COMPENSATION INSURANCE A. HOW THIS INSURANCE APPLIES This workers compensation insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. Bodily injury by accident must occur during the policy period. 2. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. B. WE WILL PAY We will pay promptly when due the benefits required of you by the workers compensation LAW. C. WE WILL DEFEND We have the right and duty to defend at our expense any claim, proceeding or suit against you for benefits payable by this insurance. We have the right to investigate and settle these claims, proceedings or suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. D. WE WILL ALSO PAY We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding or suit we defend: 1. reasonable expenses incurred at our request, but not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amount payable under this insurance; WC 00 00 00 A 1 OF 7 INSURED'S 3. litigation costs taxed against you; 4. interest on a judgment as required by law until we offer the amount due under this insurance; and 5. expenses we incur. E. OTHER INSURANCE We will not pay more than our share of benefits and costs covered by this insurance and other insurance or self-insurance. Subject to any limits of liability that may apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance will be equal until the loss is paid. F. PAYMENTS YOU MUST MAKE You are responsible for any payments in excess of the benefits regularly provided by the workers compensation law including those required be- cause: 1. of your serious and willful misconduct; 2. you knowingly employ an employee in violation of law; 3. you fail to comply with a health or safety law or regulation; or 4. you discharge, coerce or otherwise discriminate against any employee in violation of the workers compensation law. If we make any payments in excess of the benefits regularly provided by the workers compensation law on your behalf, you will reimburse us promptly. G. RECOVERY FROM OTHERS We have your rights, and the rights of persons entitled to the benefits of this insurance, to recover our payments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. H. STATUTORY PROVISIONS These statements apply where they are required by law. 1. As between an injured worker and us, we have notice of the injury when you have notice. 2. Your default or the bankruptcy or insolvency of you or your estate will not relieve us of our duties under this insurance after an injury occurs. 3. We are directly and primarily liable to any person entitled to the benefits payable by this insurance. Those persons may enforce our duties; so may an agency authorized by law. Enforcement may be against us or against you and us. 4. Jurisdiction over you is jurisdiction over us for purposes of the workers compensation law. We are bound by decisions against you under that law, subject to the provisions of this policy that are not in conflict with that law. 5. This insurance conforms to the parts of the workers compensation law that apply to: a. benefits payable by this insurance or; b. special taxes, payments into security or other special funds, and assessments payable by us under that law. 6. Terms of this insurance that conflict with the workers compensation law are changed by this statement to conform to that law. Nothing in these paragraphs relieves you of your duties under this policy. PART TWO - EMPLOYERS LIABILITY INSURANCE A. HOW THIS INSURANCE APPLIES This employers liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must arise out of and in the course of the injured employee's employment by you. 2. The employment must be necessary or incidental to your work in a state or territory listed in Item 3.A. of the Information Page. 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. If you are sued, the original suit and any related legal actions for damages for bodily injury WC 00 00 00 A 2 of 7 INSURED'S COPY by accident or by disease must be brought in the United States of America, its territories or possessions, or Canada. B. WE WILL PAY We will pay all sums you legally must pay as damages because of bodily injury to your employees, provided the bodily injury is covered by this Employers Liability Insurance. The damages we will pay, where recovery is permitted by law, include damages: 1. for which you are liable to a third party by reason of a claim or suit against you by that third party to recover the damages claimed against such third party as a result of injury to your employee; 2. for care and loss of services; and 3. for consequential bodily injury to a spouse, child, parent, brother or sister of the injured employee; provided that these damages are the direct consequence of bodily injury that arises out of and in the course of the injured employee's employment by you; and 4. because of bodily injury to your employee that arises out of and in the course of employment, claimed against you in a capacity other than as employer. C. EXCLUSIONS This insurance does not cover: 1. liability assumed under a contract. This exclusion does not apply to a warranty that your work will be done in a workmanlike manner; 2. punitive or exemplary damages because of bodily injury to an employee employed in violation of law; 3. bodily injury to an employee while employed in violation of law with your actual knowledge or the actual knowledge of any of your executive officers; 4. any obligation imposed by a workers compensation, occupational disease, unemployment compensation, or disability benefits law, or any similar law; 5. bodily injury intentionally caused or aggravated by you; 6. bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America or Canada who is temporarily outside these countries; 7. damages arising out of coercion, criticism, demotion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimination against or termination of any employee, or any personnel practices, policies, acts or omissions. 8. bodily injury to any person in work subject to the Longshore and Harbor Workers' Compensation Act (33 USC Sections 901-950), the Nonappropriated Fund Instrumentalities Act (5 USC Sections 8171-8173), the Outer Continental Shelf Lands Act (43 USC Sections 1331-1356), the Defense Base Act (42 USC Sections 1651-1654), the Federal Coal Mine Health and Safety Act of 1969 (30 USC Sections 901-942), any other federal workers or workmen's compensation law or other federal occupational disease law, or any amendments to these laws. 9. bodily injury to any person in work subject to the Federal Employers' Liability Act (45 USC Sections 51-60), any other federal laws obligating an employer to pay damages to an employee due to bodily injury arising out of or in the course of employment, or any amendments to those laws. 10. bodily injury to a master or member of the crew of any vessel. 11. fines or penalties imposed for violation of federal or state law. 12. damages payable under the Migrant and Seasonal Agricultural Worker Protection Act (29 USC Sections 1801-1872) and under any other federal law awarding damages for violation of those laws or regulations issued thereunder, and any amendments to those laws. D. WE WILL DEFEND We have the right and duty to defend, at our expense, any claim, proceeding or suit against you for damages payable by this insurance. We have the right to investigate and settle these claims, proceedings and suits. WC 00 00 00 A 3 of 7 INSURED'S COPY We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. We have no duty to defend or continue defending after we have paid our applicable limit of liability under this insurance. E. WE WILL ALSO PAY We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim proceeding, or suit we defend; 1. reasonable expenses incurred at our request; but not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the limit of our liability under this insurance; 3. litigation costs taxed against you; 4. interest on a judgment as required by law until we offer the amount due under this insurance; and 5. expenses we incur. F. OTHER INSURANCE We will not pay more than our share of damages and costs covered by this insurance and other insurance or self-insurance. Subject to any limits of liability that apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance and self-insurance will be equal until the loss is paid. G. LIMITS OF LIABILITY Our liability to pay for damages is limited. Our limits of liability are shown in Item 3.B. of the Information Page. They apply as explained below. 1. Bodily Injury by Accident. The limit shown for "bodily injury by accident-each accident" is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident. A disease is not bodily injury by accident unless it results directly from bodily injury by accident. 2. Bodily Injury by Disease. The limit shown for "bodily injury by disease-policy limit" is the most we will pay for all damages covered by this insurance and arising out of bodily injury by disease, regardless of the number of employees who sustain bodily injury by disease. The limit shown for "bodily injury by disease each employee" is the most we will pay for all damages because of bodily injury by disease to any one employee. Bodily injury by disease does not include disease that results directly from a bodily injury by accident. 3. We will not pay any claims for damages after we have paid the applicable limit of our liability under this insurance. RECOVERY FROM OTHERS We have your rights to recover our payment from anyone liable for an injury covered by this insurance. You will do everything necessary to protect those rights for us and to help us enforce them. ACTIONS AGAINST US There will be no right of action against us under this insurance unless: 1. You have complied with all the terms of this policy; and 2. The amount you owe has been determined with our consent or by actual trial and final judgment. This insurance does not give anyone the right to add us as a defendant in an action against you to determine your liability. The bankruptcy or insolvency of you or your estate will not relieve us of our obligations under this Part. PART THREE - OTHER STATES INSURANCE A. HOW THIS INSURANCE APPLIES 1. This other states insurance applies only if one or more states are shown in Item 3-C. of the Information Page. 2. If you begin work in any one of those states after the effective date of this policy and are not insured or are not self-insured for such work, all revisions of the policy will apply as though that state were listed in Item 3.A. of the Information Page 3. We will reimburse you for the benefits required by the workers compensation law of that state if we are not permitted to pay the benefits directly to persons entitled to them. 4. If you have work on the effective date of this policy in any state not listed in Item 3.A. of the WC 00 00 00 A 4 OF 7 INSURED'S COPY Information Page, coverage will not be afforded for that state unless we are notified within thirty days. B. NOTICE Tell us at once if you begin work in any state listed in Item 3.C. of the Information Page. PART FOUR - YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered by this policy. Your other duties are listed here. 1. Provide for immediate medical and other services required by the workers compensation law. 2. Give us or our agent the names and addresses of the injured persons and of witnesses, and other information we may need. 3. Promptly give us all notices, demands and legal papers related to the injury, claim, proceeding or suit. 4. Cooperate with us and assist us, as we may request, in the investigation, settlement or defense of any claim, proceeding or suit. 5. Do nothing after an injury occurs that would interfere with our right to recover from others. 6. Do not voluntarily make payments, assume obligations or incur expenses, except at your own cost. PART FIVE - PREMIUM A. OUR MANUALS All premium for this policy will be determined by our manuals of rules, rates, rating plans and classifications. We may change our manuals and apply the changes to this policy if authorized by law or a governmental agency regulating this insurance. B. CLASSIFICATIONS Item 4 of the Information Page shows the rate and premium basis for certain business or work classifications. These classifications were assigned based on an estimate of the exposures you would have during the policy period. If your actual exposures are not properly described by those classifications, we will assign proper classifications, rates and premium basis by endorsement to this policy. C. REMUNERATION Premium for each work classification is determined by multiplying a rate times a premium basis. Remuneration is the most common premium basis. This premium basis includes payroll and all other remuneration paid or payable during the policy period for the services of: 1. All your officers and employees engaged in work covered by this policy; and 2. All other persons engaged in work that could make us liable under Part One (Workers Compensation Insurance) of this policy. If you do not have payroll records for these persons, the contract price for their services and materials may be used as the premium basis. This paragraph 2 will not apply if you give us proof that the employers of these persons lawfully secured their workers compensation obligations. D. PREMIUM PAYMENTS You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. E. FINAL PREMIUM The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the balance. If it is less, we will refund the balance to you. The final premium will not be less than the highest minimum premium for the classifications covered by this policy. If this policy is canceled, final premium will be determined in the following way unless our manuals provide otherwise. 1. If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. 2. If you cancel, final premium will be more than pro rata; it will be based on the time this policy was in force, and increased by our short rate WC 00 00 00 A 5 OF 7 INSURED'S COPY cancellation table and procedure. Final premium will not be less than the minimum premium. F. RECORDS You will keep records of information needed to compute premium. You will provide us with copies of those records when we ask for them. G. AUDIT You will let us examine and audit all your records that relate to this policy. These records include ledgers, journals, registers, vouchers, contracts, tax reports, payroll and disbursement records, and programs for storing and retrieving data. We may conduct the audits during regular business hours during the policy period and within three years after the policy period ends. Information developed by audit will be used to determine final premium. Insurance rate service organizations have the same rights we have under this provision. PART SIX - CONDITIONS A. INSPECTION We have the right, but are not obliged to inspect your workplaces at any time. Our inspections are not safety inspections. They relate only to the insurability of the workplaces and the premiums to be charged. We may give you reports on the conditions we find. We may also recommend changes. While they may help reduce losses, we do not undertake to perform the duty of any person to provide for the health or safety of your employees or the public. We do not warrant that your workplaces are safe or healthful or that they comply with laws, regulations, codes or standards. Insurance rate service organizations have the same rights we have under this provision. B. LONG TERM POLICY If the policy period is longer than one year and sixteen days, all provisions of this policy will apply as though a new policy were issued on each annual anniversary that this policy is in force. C. TRANSFER OF YOUR RIGHTS AND DUTIES Your rights or duties under this policy may not be transferred without our written consent. If you die and we receive notice within thirty days after your death, we will cover your legal representative as insured. D. CANCELLATION 1. You may cancel this policy. You must mail or deliver advance written notice to, us stating when the cancellation is to take effect. 2. We may cancel this policy. We must mail or deliver to you not less than ten days advance written notice stating when the cancellation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 3. The policy period will end on the day and hour stated in the cancellation notice. 4. Any of these provisions that conflicts with a law that controls the cancellation of the insurance in this policy is changed by this statement to comply with that law. E. SOLE REPRESENTATIVE The insured first named in Item 1 of the Information Page will act on behalf of all insureds to change this policy, receive return premium, and give or receive notice of cancellation. WC 00 00 00 A 6 of 7 INSURED'S COPY In WITNESS WHEREOF, the company has caused this policy to be executed and attested, but this policy shall not be valid unless countersigned by a duly authorized representative of the company. /s/ WILLIAM D. SMITH /s/ [ILLEGIBLE] -------------------- --------------- President President The Insurance Company National Union Fire of The State of Pennsylvania Insurance Company of Birmingham Fire Insurance Pittsburgh, PA Company of Pennsylvania /s/ WALTER L. MOONEY /s/ [ILLEGIBLE] -------------------- --------------- President President Commerce and Industry American Home Insurance Company Assurance Company /s/ ELIZABETH M. TUCK --------------------- Secretary National Union Fire Insurance Company of Pittsburgh, PA American Home Assurance Company The Insurance Company of The State of Pennsylvania Birmingham Fire Insurance Company of Pennsyivania Commerce and Industry Insurance Company WC 00 00 00 A 7 of 7 INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-46 IDAHO - ------------------ -------- ------------------------------ POLICY PREFIX & NO. SCHEDULE STATE EMPLOYER/UNEMPLOYMENT ID ------------------------------- INTRA/INDEPENDENT STATE RISK ID - ----------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ----------------------------------------------------------------------------------------------------------------------- Entries in this item, except as specifically provided elsewhere in this policy, do not modify Code Estimated Total Per $100 of Estimated any of the other provisions of this policy. No. Annual Remuneration Remuneration Annual Premiums OUTSOURCE INTERNATIONAL, INC. JOB SITE ONLY BOISE, ID 83701 CLERICAL OFFICE EMPLOYEES NOC 8810 102,200 0.43 439 UNMODIFIED PREMIUM 439 INCREASED LIMITS MINIMUM PREMIUM -EMPLOYERS LIAB 9812 14 BALANCE TO MINIMUM - EMPLOYERS LIABILITY 9848 136 TOTAL UNMODIFIED PREMIUM 589 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 - 124 MODIFIED STANDARD PREMIUM 465 LOSS REIMBURSEMENT $250,000 9862 - 327 UNDISCOUNTED PREMIUM 138 ______ TO MINIMUM 0990 12 ______ ESTIMATED ANNUAL PREMIUM 150 TOTAL DUE 150 - ----------------------------------------------------------------------------------------------------------------------- WC 7754 (Ed. 4-81) INSURED'S COPY LARGE RISK RATING PLAN ENDORSEMENT (SHORT FORM) This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-46 Issued to OUTSOURCE INTERNATIONAL, INC By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA The premium for this policy will be determined according to the Large Risk Rating Plan Endorsement attached to policy NO. RMWC 2177940 53820 COUNTERSIGNED BY (Ed. 07-92) ______________________________________________ AUTHORIZED REPRESENTATIVE INSURED'S COPY DEFENSE BASE ACT COVERAGE ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-46 Issued to OUTSOURCE INTERNATIONAL, INC By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to the work described in the Schedule or described on the Information Page as subject to the Defense Base Act. The policy applies to that work as though the location included in the description of the work were a state named in Item 3.A. of the Information Page. General Section C. WORKERS' COMPENSATION LAW is replaced by the following: C. WORKERS' COMPENSATION LAW Workers' Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page and the Defense Base Act (42 USC Sections 1651-1654). It includes any amendments to those laws that are in effect during the policy period. It does not include any other federal workers or workmen's compensation law, other federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. Part Two (Employers Liability Insurance), C. Exclusions., exclusion 8, does not apply to work subject to the Defense Base Act. DESCRIPTION OF WORK Schedule NO WORK AT THIS TIME. IT IS AGREED THAT IF ANY WORK IS SUBJECT TO THE DEFENSE BASE ACT, THE INSURER WILL ENDORSE THE POLICY WITHIN SIXTY (60) DAYS OF NOTIFICATION. WC 00 01 01 A COUNTERSIGNED BY (Ed. 4-92) ___________________________________________ AUTHORIZED REPRESENTATIVE INSURED'S COPY LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 WC 217-79-46 Issued to OUTSOURCE INTERNATIONAL, INC. By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to work subject to the Longshore and Harbor Workers' Compensation Act in a state shown in the Schedule. The policy applies to that work as though that state were listed in Item 3.A. of the Information Page. General Section C. WORKERS' COMPENSATION LAW is replaced by the following: C. WORKERS' COMPENSATION LAW Workers' Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page and the Longshore and Harbor Workers' Compensation Act (33 USC Sections 901-950). It includes any amendments to those laws that are in effect during the policy period. It does not include any other federal workers or workmen's compensation law, other federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. Part Two (Employers Liability Insurance), C. Exclusions., exclusion 8, does not apply to work subject to the Longshore and Harbor Workers' Compensation Act. This endorsement does not apply to work subject to the Defense Base Act, the Outer Continental Shelf Lands Act, or the Nonappropriated Fund Instrumentalities Act. Schedule STATE LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE PERCENTAGE IDAHO 29.00 The rates for classifications with code numbers not followed by the letter "F" are rates for work not ordinarily subject to the Longshore and Harbor Workers' Compensation Act. If this policy covers work under such classifications, and if the work is subject to the Longshore and Harbor Workers' Compensation Act, those non-F classification rates will be increased by the Longshore and Harbor Workers' Compensation Act Coverage Percentage shown in the Schedule. WC 00 01 06 A COUNTERSIGNED BY (Ed. 4-92) _____________________________________________ AUTHORIZED REPRESENTATIVE INSURED'S COPY ALTERNATE EMPLOYER ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-46 Issued to OUTSOURCE INTERNATIONAL, INC By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only with respect to bodily injury to your employees while in the course of special or temporary employment by the alternate employer in the state named in Item 2 of the Schedule. Part One (Workers Compensation Insurance) and Part Two (Employers Liability Insurance) will apply as though the alternate employer is insured. If an entry is shown in Item 3 of the Schedule the insurance afford by this endorsement applies only to work you perform under the contract or at the project named in the Schedule. Under Part One (Workers Compensation Insurance) we will reimburse the alternate employer for the benefits required by the workers compensation law if we are not permitted to pay the benefits directly to the persons entitled to them. The insurance afforded by this endorsement is not intended to satisfy the alternate employer's duty to secure its obligations under the workers compensation law. We will not file evidence of this insurance on behalf of the alternate employer with any government agency. We will not ask any other insurer of the alternate employer to share with us a loss covered by this endorsement. Premium will be charged for your employees while in the course of special or temporary employment by the alternate employer. The policy may be cancelled according to its terms without sending notice to the alternate employer. Part four (Your Duties If Injury Occurs) applies to you and the alternate employer. the alternate employer will recognize our right to defend under Parts One and Two and our rights to inspect under Part Six. SCHEDULE 1. ALTERNATE EMPLOYER ADDRESS 2. STATE OF SPECIAL OR TEMPORARY EMPLOYMENT 3. CONTRACT OR PROJECT "ANY CLIENT IS INCLUDED AS AN ALTERNATE EMPLOYER AS RESPECTS THE USE OF TEMPORARY OR LEASED EMPLOYEES OF OUTSOURCE INTERNATIONAL AND AFFILIATED RELATED COMPANIES PER WRITTEN AGREEMENT BETWEEN PARTIES PRIOR TO LOSS." WC 00 03 01A COUNTERSIGNED BY (Ed. 02-89) ______________________________________________ AUTHORIZED REPRESENTATIVE INSURED'S COPY VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective forms a part of Policy No. 12:01 AM 01/01/97 RM WC 217-79-46 Issued to OUTSOURCE INTERNATIONAL, INC By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement adds Voluntary Compensation Insurance to the policy. A. HOW THIS INSURANCE APPLIES This insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must be sustained by an employee included in the group of employees described in the Schedule. 2. The bodily injury must arise out of and in the course of employment necessary or incidental to work in a state listed in the Schedule. 3. The bodily injury must occur in the United States of America, its territories or possessions, or Canada, and may occur elsewhere if the employee is a United States or Canadian citizen temporarily away from those places. 4. Bodily injury by accident must occur during the policy period. 5. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. B. WE WILL PAY We will pay an amount equal to the benefits that would be required of you if you and your employees described in the Schedule were subject to the workers compensation law shown in the Schedule. We will pay those amounts to the persons who would be entitled to them under the law. C. EXCLUSIONS This insurance does not cover: 1. any obligation imposed by a workers compensation or occupational disease law, or any similar law. 2. bodily injury intentionally caused or aggravated by you. D. BEFORE WE Pay Before we pay benefits to the persons entitled to them, they must: 1. Release you and us, in writing, of all responsibility for the injury or death. 2. Transfer to us their right to recover from others who may be responsible for the injury or death. 3. Cooperate with us and do everything necessary to enable us to enforce the right to recover from others. If the persons entitled to the benefits of this insurance fail to do those things, our duty to pay ends at once. If they claim damages from you or from us for the injury or death, our duty to pay ends at once. WC 00 03 11 A (Ed. 8-91) Page 1 of 2 INSURED'S COPY E. RECOVERY FROM OTHERS If we make a recovery from others, we will keep an amount equal to our expenses of recovery and the benefits we paid. We will pay the balance to the persons entitled to it. If the persons entitled to the benefits of this insurance make a recovery from others, they must reimburse us for the benefits we paid them. F. EMPLOYERS LIABILITY INSURANCE Part Two (Employers Liability Insurance) applies to bodily injury covered by this endorsement as though the State of employment shown in the Schedule were shown in Item 3.A of the Information Page. SCHEDULE DESIGNATED WORKERS EMPLOYEES STATE OF EMPLOYMENT COMPENSATION LAW - --------- ------------------- ------------------ ALL OFFICERS AND ALL STATES EXCEPT STATE OF HIRE EMPLOYEES, NOT SUBJECT AL,AZ,IA,IN,KY,LA TO THE WORKERS COMPENSA- MA,MI,MN,MO,MS,NE TION LAW EXCEPT MASTERS NM,NY,PA,SC,TN,TX, OR MEMBERS OF THE CREW UT,WI,MD,VA,CA,OR OF ANY VESSEL. UT,WI,MD,VA,CA,OR This endorsement does not apply in New Jersey, Nevada, North Dakota, Ohio, Washington, Wisconsin, West Virginia, Wyoming, and Maine. WC 00 03 11 A COUNTERSIGNED BY (Ed. 8-91) _____________________________________________ AUTHORIZED REPRESENTATIVE Page 2 of 2 INSURED'S COPY EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy.) This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. Issued to OUTSOURCE INTERNATIONAL, INC RM WC 217-79-46 BY THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA The premium for the policy will be adjusted by an experience rating modification factor. The factor was not available when the policy was issued. The factor, if any, shown on the Information Page is an estimate. We will issue an endorsement to show the proper factor, if different from the factor shown, when it is calculated. WC 00 04 03 COUNTERSIGNED BY (Ed. 4-84) _____________________________________________ AUTHORIZED REPRESENTATIVE INSURED'S COPY NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-46 Issued to OUTSOURCE INTERNATIONAL, INC BY THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA Experience rating is mandatory for all eligible insureds. The experience rating modification factor, if any, applicable to this policy, may change if there is a change in your ownership or in that of one or more of the entities eligible to be combined with you for experience rating purposes. Change in ownership includes sales, purchases, other transfers, mergers, consolidations, dissolutions, formations of a new entity and other changes provided for in the applicable experience rating plan manual. You must report any change in ownership to us in writing within 90 days of such change. Failure to report such changes within this period may result in revision of the experience rating modification factor used to determine your premium. THIS ENDORSEMENT IS NOT APPLICABLE IN NEW JERSEY, PENNSYLVANIA, MICHIGAN, ALASKA, CALIFORNIA, DELAWARE, MAINE OR TEXAS. WC 00 04 14 COUNTERSIGNED BY (Ed. 7-90) _____________________________________________ AUTHORIZED REPRESENTATIVE INSURED'S COPY PAGE 001 ENDORSEMENT # 00001 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-46 Issued to: OUTSOURCE INTERNATIONAL, INC By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA NAMED INSUREDS FEIN -------------- ---- 00001 OUTSOURCE INTERNATIONAL, INC 592754571 00002 SYNADYNE 1 650021598 (DBA)PAYROLL PARTNERS 00003 LABOR WORLD OF AMERICA, INC. 592754571 (DBA)SYNADINE III 00004 OUTSOURCE FRANCHISING, INC. 592754571 00005 SYNADYNE 11 650021598 (DBA)PAYROLL PARTNERS 00006 SYNADYNE IV 650021598 00007 SYNADYNE V 650021598 00008 CAPITAL STAFFING FUND, INC. 592754571 00009 SMSB ASSOCIATES, INC. 592754571 _____________________________________________ Issue Date: 04/10/97 Authorized Representative Iw0003 INSURED'S COPY PAGE 001 ENDORSEMENT # 00002 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-46 Issued to: OUTSOURCE INTERNATIONAL, INC BY: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA Additional Locations -------------------- 00001 8000 N FEDERAL HIGHWAY BOCA RATON FL 33487 00002 JOB SITE ONLY BOISE ID 83701 00003 JOB SITE ONLY BOISE ID 83701 00004 JOB SITE ONLY BOISE ID 83701 00005 JOB SITE ONLY BOISE ID 83701 00006 JOB SITE ONLY BOISE ID 83701 00007 JOB SITE ONLY BOISE ID 83701 00008 JOB SITE ONLY BOISE ID 83701 00009 JOB SITE ONLY BOISE ID 83701 00010 JOB SITE ONLY BOISE ID 83701 _____________________________________________ Issue Date: 04/10/97 Authorized Representative Iw0004 INSURED'S COPY ENDORSEMENT # 00003 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-46 Issued to: OUTSOURCE INTERNATIONAL, INC By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA NOTICE OF CANCELLATION PART SIX, PARAGRAPH D.2. OF THE WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY IS REPLACED BY THE FOLLOWING: WE MAY CANCEL THIS POLICY. WE MUST MAIL OR DELIVER TO YOU NOT LESS THAN NINETY (90) DAYS ADVANCE WRITTEN NOTICE, TEN (10) DAYS FOR NONPAYMENT OF PREMIUM STATING WHEN THE CANCELLATION IS TO TAKE EFFECT. MAILING THAN NOTICE TO YOU AT YOUR MAILING ADDRESS SHOWN IN ITEM I OF THE INFORMATION PAGE WILL BE SUFFICIENT TO PROVE NOTICE. _____________________________________________ Issue Date: 04/10/97 Authorized Representative Iw0014 INSURED'S COPY ENDORSEMENT This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-46 Issued to: OUTSOURCE INTERNATIONAL, INC By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA THIS POLICY PROVIDES NO COVERAGE IN THE STATE OF MAINE. _____________________________________________ Issue Date: 04/10/97 Authorized Representative wc880001 INSURED'S COPY ISSUED BY THE STOCK INSURANCE COMPANY HEREIN CALLED THE COMPANY AGENT NUMBER POLICY NUMBER THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA 13889 84324 RM WC 217-79-48 INCORPORATED UNDER THE LAWS OF PENNSYLVANIA ITEM 1. NAMED INSURED: MAILING ADDRESS IDENTIFICATION NO. OUTSOURCE INTERNATIONAL, INC. [LOGO] Member Companies of 8000 NORTH FEDERAL HIGHWAY American International Group BOCA RATON FL 33487-0000 EXECUTIVE OFFICES: 70 PINE STREET, NEW YORK, N.Y. 10270 I.D.# 917-356254 PRODUCERS NAME & MAILING ADDRESS WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CENTURY FINANCIAL SERVICES INFORMATION PAGE 185 N W SPANISH RIVER BLVD 170 BOCA RATON FL 33481-1088 - -------------------------------------------------------------------------------- INSURED IS CORPORATION PREVIOUS POLICY NUMBER RMWC 2117626 (RENEWAL) - -------------------------------------------------------------------------------- OTHER WORKPLACES NOT SHOWN ABOVE - -------------------------------------------------------------------------------- ITEM 2 POLICY PERIOD 12:01 A.M. STANDARD TIME AT THE INSURED'S MAILING ADDRESS FROM 01/01/97 TO 01/01/98 - -------------------------------------------------------------------------------- ITEM 3 A. WORKERS COMPENSATION INSURANCE: PART ONE OF THE POLICY APPLIES TO WORKERS COMPENSATION LAW OF THE STATES LISTED HERE: OR ------------------------------------------------------------------------- B. EMPLOYERS LIABILITY INSURANCE: PART TWO OF THE POLICY APPLIES TO THE WORK IN EACH STATE LISTED IN ITEM 3.A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE: BODILY INJURY BY ACCIDENT $1,000,000 EACH ACCIDENT BODILY INJURY BY DISEASE $1,000,000 POLICY LIMIT BODILY INJURY BY DISEASE $1,000,000 EACH EMPLOYEE ------------------------------------------------------------------------- C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO THE STATES, IF ANY, LISTED HERE: NONE - -------------------------------------------------------------------------------- ITEM 4 THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, CLASSIFICATIONS, RATES AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. ------------------------------------------------------------------------- ESTIMATED TOTAL RATE PER ESTIMATED CLASSIFICATIONS CODE NUMBER REMUNERATION $100 OF RE- PREMIUM [X]ANNUAL [ ]3 YEAR MUNERATION [X]ANNUAL [ ]3 YEAR - -------------------------------------------------------------------------------- SEE ATTACHED SCHEDULES TAXES/ASSESSSMENTS/SURCHARGES $274 - -------------------------------------------------------------------------------- EXPENSE CONSTANT (EXCEPT WHERE APPLICABLE BY STATE) $160 OR - -------------------------------------------------------------------------------- MINIMUM PREMIUM $750 OR TOTAL ESTIMATED PREMIUM $6,258 - -------------------------------------------------------------------------------- Indicated below, interim adjustments of premium shall be made: [ ]Semi-Annually [ ]Quarterly [ ]Monthly DEPOSIT PREMIUM 6,258 - -------------------------------------------------------------------------------- ENDORSEMENTS (FORM NUMBER) SEE ATTACHED SCHEDULE - -------------------------------------------------------------------------------- 04/01/97 ATLANTA 07 - ------------------------------------------------- ISSUE DATE PRINT DATE: 04/09/97 ISSUING OFFICE ---------------------------------------- 39967 AUTHORIZED REPRESENTATIVE WC 00 00 INSURED'S COPY FORMS SCHEDULE Policy Number : RM WC 217-79-48 Effective Date: 01/01/97 - -------------------------------------------------------------------------------- WC000000A TERMS & CONDITIONS 53820 LARGE RISK RATING PLAN ENDT WC000106A USL&H WC ACT COVERAGE END. WC000301A ALTERNATE EMPLOYER ENDORSEMENT WCOOO311A VOL COMP & EL COVERAGE ENDT WC000403 EXPERIENCE RATING MOD FACTOR WC000414 NOTIFICATION OF CHG OWNERSHIP LWNOR NOTICE TO WC INS. POLICOYHOLDERS LWNOREGON OREGON BOOKLET WC880001 ST OF ME EXCL LWO418 (ED. 1-92) INSURED'S COPY WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY National Union Fire Insurance Company of Pittsburgh, Pa. [LOGO] American Home Assurance Company Member Companies of American International Group, Inc. The Insurance Company of EXECUTIVE OFFICES The State of Pennsylvania 70 PINE STREET NEW YORK, N.Y. 10270 Birmingham Fire Insurance Company of Pennsylvania Commerce and Industry Insurance Company Coverage is provided by the Company designated on the Information Page A Stock Insurance Company WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY QUICK REFERENCE BEGINNING ON PAGE Information Page..........................................................i GENERAL SECTION...........................................................1 A. The Policy........................................................1 B. Who Is Insured....................................................1 C. Workers Compensation Law..........................................1 D. State.............................................................1 E. Locations.........................................................1 PART ONE-WORKERS COMPENSATION INSURANCE...................................1 A. How This Insurance Applies........................................1 B. We Will Pay.......................................................1 C. We Will Defend....................................................1 D. We Will Also Pay..................................................1 E. Other Insurance...................................................2 F. Payments You Must Make............................................2 G. Recovery From Others..............................................2 H. Statutory Provisions..............................................2 THESE POLICY PROVISIONS WITH THE INFORMATION PAGE AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THIS POLICY. "INCLUDES COPYRIGHT MATERIAL OF THE NATIONAL COUNCIL ON COMPENSATION INSURANCE, USED WITH ITS PERMISSION. COPYRIGHT 1983 NATIONAL COUNCIL ON COMPENSATION INSURANCE" 39638C(04/92) WC 00 00 00 A (STANDARD) INSURED'S COPY ED 4 92 QUICK REFERENCE - CONTINUED BEGINNING ON PAGE PART TWO - EMPLOYERS LIABILITY INSURANCE ................................ 2 A. How This Insurance Applies .................................. 2 B. We Will Pay ................................................. 3 C. Exclusions .................................................. 3 D. We Will Defend .............................................. 3 E. We Will Also Pay ............................................ 4 F. Other Insurance ............................................. 4 G. Limits of Liability ......................................... 4 H. Recovery From Others ........................................ 4 I. Action Against Us ........................................... 4 PART THREE - OTHER STATES INSURANCE ..................................... 4 A. How This Insurance Applies .................................. 4 B. Notice ...................................................... 5 PART FOUR - YOUR DUTIES IF INJURY OCCURS ................................ 5 PART FIVE - PREMIUM ..................................................... 5 A. Our Manuals ................................................. 5 B. Classifications ............................................. 5 C. Remuneration ................................................ 5 D. Premium Payments ............................................ 5 E. Final Premium ............................................... 5 F. Records ..................................................... 6 G. Audit ....................................................... 6 PART SIX - CONDITIONS ................................................... 6 A. Inspection .................................................. 6 B. Long Term Policy ............................................ 6 C. Transfer of Your Rights and Duties .......................... 6 D. Cancellation ................................................ 6 E. Sole Representative ......................................... 6 IMPORTANT: This Quick Reference is NOT part of the Workers Compensation and Employers Liability Policy and does NOT provide coverage. Refer to the Workers Compensation and Employers Liability Policy itself for actual contractual provisions. PLEASE READ THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CAREFULLY INSURED'S COPY ATTACH FORM AND ENDORSEMENTS (IF ANY) HERE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to ALL terms of this policy, WE agree with you as follows. GENERAL SECTION A. THE POLICY This policy includes at its effective date the Information Page and all endorsements and schedules listed there. It is a contract of insurance between you (the employer named in Item 1 of the Information Page) and us (the insurer named on the Information Page). The only agreements relating to this insurance are stated in this policy. The terms of this policy may not be changed or waived except by endorsement issued by us to be part of this policy. B. WHO IS INSURED You are insured if you are an employer named in Item 1 of the Information Page. If that employer is a partnership, and if you are one of its partners, you are insured, but only in your capacity as an employer of the partnership's employees. C. WORKERS COMPENSATION LAW Workers Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page. It includes any amendments to that law which are in effect during the policy period. It does not include any federal workers or workmen's compensation law, any federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. D. STATE State means any state of the United States of America, and the District of Columbia. E. LOCATIONS This policy covers all of your workplaces listed in Items 1 or 4 of the Information Page; and it covers all other workplaces in Item 3.A states unless you have other insurance or are self-insured for such workplaces. PART ONE - WORKERS COMPENSATION INSURANCE A. HOW THIS INSURANCE APPLIES This workers compensation insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. Bodily injury by accident must occur during the policy period. 2. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. B. WE WILL PAY We will pay promptly when due the benefits required of you by the workers compensation law. C. WE WILL DEFEND We have the right and duty to defend at our expense any claim, proceeding or suit against you for benefits payable by this insurance. We have the right to investigate and settle these claims, proceedings or suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. D. WE WILL ALSO PAY We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding or suit we defend: 1. reasonable expenses incurred at our request, but not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amount able under this insurance; WC 00 00 00 A 1 OF 7 INSURED'S COPY 3. litigation costs taxed against you; 4. interest on a judgment as required by law until we offer the amount due under this insurance; and 5. expenses we incur. E. OTHER INSURANCE We will not pay more than our share of benefits and costs covered by this insurance and other insurance or self-insurance. Subject to any limits of liability that may apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of ail remaining insurance will be equal until the loss is paid. F. PAYMENTS YOU MUST MAKE You are responsible for any payments in excess of the benefits regularly provided by the workers compensation law including those required because: 1. of your serious and willful misconduct; 2. you knowingly employ an employee in violation of law; 3. you fail to comply with a health or safety law or regulation; or 4. you discharge, coerce or otherwise discriminate against any employee in violation of the workers compensation law. If we make any payments in excess of the benefits regularly provided by the workers compensation law on your behalf, you will reimburse us promptly. G. RECOVERY FROM OTHERS We have your rights, and the rights of persons entitled to the benefits of this insurance, to recover our payments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. H. STATUTORY PROVISIONS These statements apply where they are required by law. 1. As between an injured worker and us, we have notice of the injury when you have notice. 2. Your default or the bankruptcy or insolvency of you or your estate will not relieve us of our duties under this insurance after an injury occurs. 3. We are directly and primarily liable to any person entitled to the benefits payable by this insurance. Those persons may enforce our duties; so may an agency authorized by law. Enforcement may be against us or against you and us. 4. Jurisdiction over you is jurisdiction over us for purposes of the workers compensation law. We are bound by decisions against you under that law, subject to the provisions of this policy that are not in conflict with that law. 5. This insurance conforms to the parts of the workers compensation law that apply to: a. benefits payable by this insurance or; b. special taxes, payments into security or other special funds, and assessments payable by us under that law. 6. Terms of this insurance that conflict with the workers compensation law are changed by this statement to conform to that law. Nothing in these paragraphs relieves you of your duties under this policy. PART TWO - EMPLOYERS LIABILITY INSURANCE A. HOW THIS INSURANCE APPLIES This employers liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must arise out of and in the course of the injured employee's employment by you. 2. The employment must be necessary or incidental to your work in a state or territory listed in Item 3.A. of the Information Page. 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. If you are sued, the original suit and any related legal actions for damages for bodily injury WC 00 00 00 A 2 of 7 INSURED'S COPY by accident or by disease must be brought in the United States of America, its territories or possessions, or Canada. B. WE WILL PAY We will pay all sums you legally must pay as damages because of bodily injury to your employees, provided the bodily injury is covered by this Employers Liability Insurance. The damages we will pay, where recovery is permitted by law, include damages: 1. for which you are liable to a third party by reason of a claim or suit against you by that third party to recover the damages claimed against such third party as a result of injury to your employee; 2. for care and loss of services; and 3. for consequential bodily injury to a spouse, child, parent, brother or sister of the injured employee; provided that these damages are the direct consequence of bodily injury that arises out of and in the course of the injured employee's employment by you; and 4. because of bodily injury to your employee that arises out of and in the course of employment, claimed against you in a capacity other than as employer. C. EXCLUSIONS This insurance does not cover: 1. liability assumed under a contract. This exclusion does not apply to a warranty that your work will be done in a workmanlike manner; 2. punitive or exemplary damages because of bodily injury to an employee employed in violation of law; 3. bodily injury to an employee while employed in violation of law with your actual knowledge or the actual knowledge of any of your executive officers; 4. any obligation imposed by a workers compensation, occupational disease, unemployment compensation, or disability benefits law, or any similar law; 5. bodily injury intentionally caused or aggravated 6. bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America or Canada who is temporarily outside these countries; 7. damages arising out of coercion, criticism, demotion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimination against or termination of any employee, or any personnel practices, policies, acts or omissions. 8. bodily injury to any person in work subject to the Longshore and Harbor Workers' Compensation Act (33 USC Sections 901-950), the Nonappropriated Fund Instrumentalities Act (5 USC Sections 8171-8173), the Outer Continental Shelf Lands Act (43 USC Sections 1331-1356), the Defense Base Act (42 USC Sections 1651-1654), the Federal Coal Mine Health and Safety Act of 1969 (30 USC Sections 901-942), any other federal workers or workmen's compensation law or other federal occupational disease law, or any amendments to these laws. 9. bodily injury to any person in work subject to the Federal Employers' Liability Act (45 USC Sections 51-60), any other federal laws obligating an employer to pay damages to an employee due to bodily injury arising out of or in the course of employment, or any amendments to those laws. 10. bodily injury to a master or member of the crew of any vessel. 11. fines or penalties imposed for violation of federal or state law. 12. damages payable under the Migrant and Seasonal Agricultural Worker Protection Act (29 USC Sections 1801-1872) and under any other federal law awarding damages for violation of those laws or regulations issued thereunder, and any amendments to those laws. D. WE WILL DEFEND We have the right and duty to defend, at our expense, any claim, proceeding or suit against you for damages payable by this insurance. We have the right to investigate and settle these claims, proceedings and suits. WC 00 00 00 A 3 of 7 INSURED'S COPY We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. We have no duty to defend or continue defending after we have paid our applicable limit of liability under this insurance. E. WE WILL ALSO PAY We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim proceeding, or suit we defend; 1. reasonable expenses incurred at our request; but not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the limit of our liability under this insurance; 3. litigation costs taxed against you; 4. interest on a judgment as required by law until we offer the amount due under this insurance; and 5. expenses we incur. F. OTHER INSURANCE We will not pay more than our share of damages and costs covered by this insurance and other insurance or self-insurance. Subject to any limits of liability that apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance and self-insurance will be equal until the loss is paid. G. LIMITS OF LIABILITY Our liability to pay for damages is limited. Our limits of liability are shown in Item 3.B. of the Information Page. They apply as explained below. 1. Bodily Injury by Accident. The limit shown for "bodily injury by accident-each accident" is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident. A disease is not bodily injury by accident unless it results directly from bodily injury by accident. 2. Bodily Injury by Disease. The limit shown for "bodily injury by disease-policy limit" is the most we will pay for all damages covered by this insurance and arising out of bodily injury by disease, regardless of the number of employees who sustain bodily injury by disease. The limit shown for "bodily injury by disease each employee" is the most we will pay for all damages because of bodily injury by disease to any one employee. Bodily injury by disease does not include disease that results directly from a bodily injury by accident. 3. We will not pay any claims for damages after we have paid the applicable limit of our liability under this insurance. H. RECOVERY FROM OTHERS We have your rights to recover our payment from anyone liable for an injury covered by this insurance. You will do everything necessary to protect those rights for us and to help us enforce them. I. ACTIONS AGAINST US There will be no right of action against us under this insurance unless: 1. You have complied with all the terms of this policy; and 2. The amount you owe has been determined with our consent or by actual trial and final judgment. This insurance does not give anyone the right to add us as a defendant in an action against you to determine your liability. The bankruptcy or insolvency of you or your estate will not relieve us of our obligations under this Part. PART THREE - OTHER STATES INSURANCE A. HOW THIS INSURANCE APPLIES 1. This other states insurance applies only if one or more states are shown in Item 3.C. of the Information Page. 2. If you begin work in any one of those states after the effective date of this policy and are not insured or are not self-insured for such work, all revisions of the policy will apply as though that state were listed in Item 3.A. of the Information Page. 3. We will reimburse you for the benefits required by the workers compensation law of that state if we are not permitted to pay the benefits directly to persons entitled to them. 4. If you have work on the effective date of this policy in any state not listed in Item 3.A. of the 4 of 7 INSURED'S COPY Information Page, coverage will not be afforded for that state unless we are notified within thirty days. B. NOTICE Tell us at once if you begin work in any state list in Item 3.C. of the Information Page. PART FOUR - YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered by this policy. Your other duties are listed here. 1. Provide for immediate medical and other services required by the workers compensation law. 2. Give us or our agent the names and addresses of the injured persons and of witnesses, and other information we may need. 3. Promptly give us all notices, demands and legal papers related to the injury, claim, proceeding or suit. 4. Cooperate with us and assist us, as we may request, in the investigation, settlement or defense of any claim, proceeding or suit. 5. Do nothing after an injury occurs that would interfere with our right to recover from others. 6. Do not voluntarily make payments, assume obligations or incur expenses, except at your own cost. PART FIVE - PREMIUM A. OUR MANUALS All premium for this policy will be determined by our manuals of rules, rates, rating plans and classifications. We may change our manuals and apply the changes to this policy if authorized by law or a governmental agency regulating this insurance. B. CLASSIFICATIONS Item 4 of the Information Page shows the rate and premium basis for certain business or work classifications. These classifications were assigned based on an estimate of the exposures you would have during the policy period. If your actual exposures are not properly described by those classifications, we will assign proper classifications, rates and premium basis by endorsement to this policy. C. REMUNERATION Premium for each work classification is determined by multiplying a rate times a premium basis. Remuneration is the most common premium basis. This premium basis includes payroll and all other remuneration paid or payable during the policy period for the services of: 1. All your officers and employees engaged in work covered by this policy; and 2. All other persons engaged in work that could make us liable under Part One (Workers Compensation Insurance) of this policy. If you do not have payroll records for these persons, the contract price for their services and materials may be used as the premium basis. This paragraph 2 will not apply if you give us proof that the employers of these persons lawfully secured their workers compensation obligations. D. PREMIUM PAYMENTS You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. E. FINAL PREMIUM The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the balance. If it is less, we will refund the balance to you. The final premium will not be less than the highest minimum premium for the classifications covered by this policy. If this policy is canceled, final premium will be determined in the following way unless our manuals provide otherwise. 1. If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. 2. If you cancel, final premium will be more than pro rata; it will be based on the time this policy was in force, and increased by our short rate WC 00 00 00 A 5 of 7 INSURED'S COPY cancellation table and procedure. Final premium will not be less than the minimum premium. F. RECORDS You will keep records of information needed to compute premium. You will provide us with copies of those records when we ask for them. G. AUDIT You will let us examine and audit all your records that relate to this policy. These records include ledgers, journals, registers, vouchers, contracts, tax reports, payroll and disbursement records, and programs for storing and retrieving data. We may conduct the audits during regular business hours during the policy period and within three years after the policy period ends. Information developed by audit will be used to determine final premium. Insurance rate service organizations have the same rights we have under this provision. PART SIX - CONDITIONS A. INSPECTION We have the right, but are not obliged to inspect your workplaces at any time. Our inspections are not safety inspections. They relate only to the insurability of the workplaces and the premiums to be charged. We may give you reports on the conditions we find. We may also recommend changes. While they may help reduce losses, we do not undertake to perform the duty of any person to provide for the health or safety of your employees or the public. We do not warrant that your workplaces are safe or healthful or that they comply with laws, regulations, codes or standards. Insurance rate service organizations have the same rights we have under this provision. B. LONG TERM POLICY If the policy period is longer than one year and sixteen days, all provisions of this policy will apply as though a new policy were issued on each annual anniversary that this policy is in force. C. TRANSFER OF YOUR RIGHTS AND DUTIES Your rights or duties under this policy may not be transferred without our written consent. If you die and we receive notice within thirty days after your death, we will cover your legal representative as insured. D. CANCELLATION 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancellation is to take effect. 2. We may cancel this policy. We must mail or deliver to you not less than ten days advance written notice stating when the cancellation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 3. The policy period will end on the day and hour stated in the cancellation notice. 4. Any of these provisions that conflicts with a law that controls the cancellation of the insurance in this policy is changed by this statement to comply with that law. E. SOLE REPRESENTATIVE The insured first named in Item 1 of the Information Page will act on behalf of all insureds to change this policy, receive return premium, and give or receive notice of cancellation. WC 00 00 00 A 6 of 7 INSURED'S COPY In WITNESS WHEREOF, the company has caused this policy to be executed and attested, but this policy shall not be valid unless countersigned by a duly authorized representative of the company. /s/ WILLIAM D. SMITH /s/ [ILLEGIBLE] -------------------- --------------- President President The Insurance Company National Union Fire of The State of Pennsylvania Insurance Company of Birmingham Fire Insurance Pittsburgh, PA Company of Pennsylvania /s/ WALTER L. MOONEY /s/ [ILLEGIBLE] -------------------- --------------- President President Commerce and Industry American Home Insurance Company Assurance Company /s/ ELIZABETH M. TUCK --------------------- Secretary National Union Fire Insurance Company of Pittsburgh, PA American Home Assurance Company The Insurance Company of The State of Pennsylvania Birmingham Fire Insurance Company of Pennsyivania Commerce and Industry Insurance Company WC 00 00 00 A 7 of 7 INSURED'S COPY STANDARD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY EXTENSION FORM RM WC 217-79-48 OREGON --------------------- ------------ ------------------------------- Policy Prefix & No. Schedule State Employer/Unemployment ID ------------------------------- Intra/Independent State Risk ID - ------------------------------------------------------------------------------------------------------------------------------- ITEM 4. CLASSIFICATION OF OPERATIONS PREMIUM BASIS RATES - ------------------------------------------------------------------------------------------------------------------------------- ENTRIES IN THIS ITEM, EXCEPT AS SPECIFICALLY CODE ESTIMATED TOTAL PER $100 OF ESTIMATED PROVIDED ELSEWHERE IN THIS POLICY, DO NOT MODIFY NO. ANNUAL REMUNERATION REMUNERATION ANNUAL PREMIUMS ANY OF THE OTHER PROVISIONS OF THIS POLICY. LABOR WORLD OF AMERICA, INC. 2424 E BURNSIDE STREET PORTLAND, OR 97214 STORE: RETAIL NOC 8017 2,800 2.23 62 TELEPHONE ANSWERING SERVICE 8810 1,576,500 0.47 7,410 UNMODIFIED PREMIUM 7,472 INCREASED LIMITS-EMPLOYER LIABILITY 3.3% 9812 247 TOTAL UNMODIFIED PREMIUM 7,719 EXPERIENCE MODIFICATION (TENTATIVE) .79 9898 (1,621) MODIFIED STANDARD PREMIUM 6,098 UNDISCOUNTED PREMIUM 6,098 ____NSE CONSTANT 0900 160 ____L ESTIMATED ANNUAL PREMIUM 6,258 ASSESSMENTS/TAXES 4.5% 0088 274 TOTAL DUE 6,532 - ------------------------------------------------------------------------------------------------------------------------- WC 7754 (ED. 4-81) INSURED'S COPY LARGE RISK RATING PLAN ENDORSEMENT (SHORT FORM) This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-48 Issued to OUTSOURCE INTERNATIONAL, INC By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA The premium for this policy will be determined according to the Large Risk Rating Plan Endorsement attached to policy No. RM WC 217-79-48 53820 COUNTERSIGNED BY _____________________________ (ED. 07-92) AUTHORIZED REPRESENTATIVE INSURED'S COPY LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-48 Issued to OUTSOURCE INTERNATIONAL, INC BY THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only to work subject to the Longshore and Harbor Workers' Compensation Act in a state shown in the Schedule. The policy applies to that work as though that state were listed in Item 3.A. of the Information Page. General Section C. WORKERS' COMPENSATION LAW is replaced by the following: C. WORKERS' COMPENSATION LAW Workers' Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page and the Longshore and Harbor Workers' Compensation Act (33 USC Sections 901-950). It includes any amendments to those laws that are in effect during the policy period. It does not include any other federal workers or workmen's compensation law, other federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. Part Two (Employers Liability Insurance), C. Exclusions., exclusion 8, does not apply to work subject to the Longshore and Harbor Workers' Compensation Act. This endorsement does not apply to work subject to the Defense Base Act, the Outer Continental Shelf Lands Act, or the Nonappropriated Fund Instrumentalities Act. Schedule STATE LONGSHORE AND HARBOR WORKERS' - ----- COMPENSATION ACT COVERAGE PERCENTAGE ------------------------------------ OREGON 64.00 The rates for classifications with code numbers not followed by the letter "F" are rates for work not ordinarily subject to the Longshore and Harbor Workers' Compensation Act. If this policy covers work under such classifications, and if the work is subject to the Longshore and Harbor Workers' Compensation Act, those non-F classification rates will be increased by the Longshore and Harbor Workers' Compensation Act Coverage Percentage shown in the Schedule. WC 00 01 06 A COUNTERSIGNED BY _____________________________ (ED. 4-92) AUTHORIZED REPRESENTATIVE INSURED'S COPY ALTERNATE EMPLOYER ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-48 Issued to OUTSOURCE INTERNATIONAL, INC By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement applies only with respect to bodily injury to your employees while in the course of special or temporary employment by the alternate employer in the state named in Item 2 of the Schedule. Part One (Workers Compensation Insurance) and Part Two (Employer Liability Insurance) will apply as though the alternate employer is insured. If an entry is shown in Item 3 of the Schedule the insurance afforded by this endorsement applies only to work you perform under the contract or at the project named in the Schedule. Under Part One (Workers Compensation Insurance) we will reimburse the alternate employer for the benefits required by the workers compensation law if we are not permitted to pay the benefits directly to the persons entitled to them. The insurance afforded by this endorsement is not intended to satisfy the alternate employer's duty to secure its obligations under the workers compensation law. We will not file evidence of this insurance on behalf of the alternate employer with any government agency. We will not ask any other insurer of the alternate employer to share with us a loss covered by this endorsement. Premium will be charged for your employees while in the course of special or temporary employment by the alternate employer. The policy may be cancelled according to its terms without sending notice to the alternate employer. Part Four (Your Duties If Injury Occurs) applies to you and the alternate employer. The alternate employer will recognize our right to defend under Parts One and Two and our right to inspect under Part Six. SCHEDULE 1 ALTERNATE EMPLOYER ADDRESS 2. STATE OF SPECIAL OR TEMPORARY EMPLOYMENT OR 3. CONTRACT OR PROJECT "ANY CLIENT IS INCLUDED AS AN ALTERNATE EMPLOYER AS RESPECTS THE USE OF TEMPORARY OR LEASED EMPLOYEES OF OUTSOURCE INTERNATIONAL AND AFFILIATED RELATED COMPANIES PER WRITTEN AGREEMENT BETWEEN THE PARTIES PRIOR TO LOSS." WC 00 03 01A COUNTERSIGNED BY ___________________________ (ED. 02-89) AUTHORIZED REPRESENTATIVE INSURED'S COPY VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-48 Issued to OUTSOURCE INTERNATIONAL, INC By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA This endorsement adds Voluntary Compensation Insurance to the policy. A. HOW THIS INSURANCE APPLIES This insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must be sustained by an employee included in the group of employees described in the Schedule. 2. The bodily injury must arise out of and in the course of employment necessary or incidental to work in a state listed in the Schedule. 3. The bodily injury must occur in the United States of America, its territories or possessions, or Canada, and may occur elsewhere if the employee is a United States or Canadian citizen temporarily away from those places. 4. Bodily injury by accident must occur during the policy period. 5. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. B. WE WILL PAY We will pay an amount equal to the benefits that would be required of you if you and your employees described in the Schedule were subject to the workers compensation law shown in the Schedule. We will pay those amounts to the persons who would be entitled to them under the law. C. EXCLUSIONS This insurance does not cover: 1. any obligation imposed by a workers compensation or occupational disease law, or any similar law. 2. bodily injury intentionally caused or aggravated by you. D. BEFORE WE PAY Before we pay benefits to the persons entitled to them, they must: 1. Release you and us, in writing, of all responsibility for the injury or death. 2. Transfer to us their right to recover from others who may be responsible for the injury or death. 3. Cooperate with us and do everything necessary to enable us to enforce the right to recover from others. If the persons entitled to the benefits of this insurance fail to do those things, our duty to pay ends at once. If they claim damages from you or from us for the injury or death, our duty to pay ends at once. WC 00 03 11 A (ED. 8-91) Page 1 of 2 INSURED'S COPY E. RECOVERY FROM OTHERS If we make a recovery from others, we will keep an amount equal to our expenses of recovery and the benefits we paid. We will pay the balance to the persons entitled to it. If the persons entitled to the benefits of this insurance make a recovery from others, they must reimburse us for the benefits we paid them. F. EMPLOYERS LIABILITY INSURANCE Part Two (Employers Liability Insurance) applies to bodily injury covered by this endorsement as though the State of employment shown in the Schedule were shown in Item 3.A of the Information Page. SCHEDULE DESIGNATED WORKERS EMPLOYEES STATE OF EMPLOYMENT COMPENSATION LAW - --------- ------------------- ---------------- ALL OFFICERS AND ALL STATES EXCEPT STATE OF HIRE EMPLOYEES NOT SUBJECT AL, AZ, IA, IN, KY, LA TO THE WORKERS COMPENSATION MA, MI, MN, M0, MS, NE, ON LAW EXCEPT MASTERS ID, NM, NY, PA, SC, TN OR MEMBERS OF THE CREW TX, UT, WI, MD, VA, CA, OF ANY VESSEL. This endorsement does not apply in New Jersey, Nevada, North Dakota, Ohio, Washington, Wisconsin, West Virginia, Wyoming, and Maine. WC 00 03 11 A COUNTERSIGNED BY ____________________________ AUTHORIZED REPRESENTATIVE (ED. 8-91) Page 2 of 2 INSURED'S COPY EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-48 Issued to OUTSOURCE INTERNATIONAL, INC By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA The premium for the policy will be adjusted by an experience rating modification factor. The factor was not available when the policy was issued. The factor, if any, shown on the Information Page is an estimate. We will issue an endorsement to show the proper factor, if different from the factor shown, when it is calculated. WC 00 04 03 COUNTERSIGNED BY _____________________________ (ED. 4-84) AUTHORIZED REPRESENTATIVE INSURED'S COPY NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/01/97 forms a part of Policy No. RM WC 217-79-48 Issued to OUTSOURCE INTERNATIONAL, INC By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA Experience rating is mandatory for all eligible insureds. The experience rating modification factor, if any, applicable to this policy, may change if there is a change in your ownership or in that of one or more of the entities eligible to be combined with you for experience rating purposes. Change in ownership includes sales, purchases, other transfers, mergers, consolidations, dissolutions, formations of a new entity and other changes provided for in the applicable experience rating plan manual. You must report any change in ownership to us in writing within 90 days of such change. Failure to report such changes within this period may result in revision of the experience rating modification factor used to determine your premium. THIS ENDORSEMENT IS NOT APPLICABLE IN NEW JERSEY, PENNSYLVANIA, MICHIGAN, ALASKA, CALIFORNIA, DELAWARE, MAINE OR TEXAS. WC 00 04 14 COUNTERSIGNED BY ____________________________ (ED. 7-90) AUTHORIZED REPRESENTATIVE INSURED'S COPY NOTICE TO OREGON WORKERS COMPENSATION INSURANCE POLICYHOLDERS DO YOU LEASE ANY OF YOUR EMPLOYEES? If you do, you must take immediate action. The 1993 Legislature passed a comprehensive law (HB2282) regulating the employee leasing industry. Under the new law, leasing companies must be registered and pay workers compensation insurance premium using their clients' experience ratings. The new law also requires that as long as you maintain your own workers compensation policy you must report the payroll for ALL workers you employ, whether leased or direct, to your insurer. You may continue to lease workers, but it is your responsibility to provide coverage and reports for workers' compensation payroll and premium purposes while your policy is in place, since your insurer is responsible for their injury claims. If you wish to lease all of your workers, and leave full responsibility with the leasing company for providing workers compensation coverage, you must cancel your current policy by giving written notice to your insurance carrier. Again, action must be taken if you lease employees. A copy of the recently adopted state Workers Compensation Division administrative rules is available upon request. If you have any questions regarding this law or the rules, please contact( fill in: INSURANCE CARRIER NAME AND OR AGENT). LWNOR COUNTERSIGNED BY ______________________________ (ED. 05-94) AUTHORIZED REPRESENTATIVE INSURED'S COPY PREPARED BY THE NATIONAL COUNCIL ON COMPENSATION INSURANCE (REPRINTED WITH PERMISSION) - -------------------------------------------------------------------------------- AN INTRODUCTION TO WORKERS COMPENSATION: BACKGROUND FOR OREGON EMPLOYERS LWNOREGON INSURED'S COPY - -------------------------------------------------------------------------------- INTRODUCTION In accordance with the intent of the Oregon law, this booklet was prepared for voluntary distribution to Oregon employers by the insurance industry. In it, you will find answers to basic questions about workers compensation insurance. LWNOREGON INSURED'S COPY NATIONAL COUNCIL ON COMPENSATION INSURANCE (NCCI) The National Council on Compensation Insurance is a voluntary, non-profit, statistical, research and ratemaking organization licensed under Oregon Revised Statutes 737.350. Supported by the insurance industry, NCCI's primary functions are the preparation and administration of rates, rating plans, and systems for workers compensation insurance. In Oregon, the NCCI prepares a schedule of rates for insureds in the assigned risk plan, subject to insurance department approval, and acts in an advisory capacity for insurers writing the rest of the business in the state. As the rating organization, it is NCCI's obligation to collect payroll and loss information, by individual classification, for each workers compensation insurance policy in the state of Oregon. In addition, the rating organization will perform inspections at employers' premises to determine the proper classifications, perform test audits, promulgate experience rating modifications, and administer the Workers Compensation Insurance Plan (WCIP) for those employers unable to obtain coverage voluntarily. WORKERS COMPENSATION RATES NCCI uses the collected payroll and loss data to actuarially determine that portion of each individual classification rate necessary to pay the losses. This amount is called the pure premium. Oregon insurers may use the pure premiums determined by NCCI or their own when preparing their rates. Each carrier applies its own 'factor' to provide for the additional costs for taxes, licenses, fees, acquisition and field supervision, and other company expenses. This 'factored' rate is the amount charged per $100 of payroll. LWNOREGON -1- INSURED'S COPY CLASSIFICATIONS: There are approximately 500 different workers compensation classifications, each of which individually describes a particular occupation. Generally, each employer will be entitled to the ONE basic classification which most accurately describes its operations. In addition, when that one basic classification does not specifically include one of the "Standard Exception" classifications (Clerical, Outside Salespersons, or Drivers), each employer may also be entitled to three additional classifications: Code 7380 Drivers Chauffeurs & Helpers; Code 8742 Salespersons, Collectors or Messengers Outside; and Code 8810 Clercial Office Employees. Your insurance carrier will advise you of the classifications applicable to your operations. However, when an employer is engaged in Construction, Erection, Stevedoring; Aircraft Operations (industrial Aid), or Trucking as a secondary business, additional classifications may be assigned. Again, your carrier will counsel you on the classifications to your operations. DIVISION OF INDIVIDUAL EMPLOYEE'S PAYROLL When any employee performs different duties which, if performed by a different worker, would qualify for a different classification assignment, you may divide that person's payroll between two or more classifications, PROVIDED separate verifiable payroll records are adequately maintained. When verifiable payroll records are not maintained, that individual's payroll must be assigned to the highest rated classification for any of the duties performed. VERIFIABLE RECORDS Verifiable records are documents completed by an employee or supervisor every time the employee changes duties. These records should display the starting time and ending time for each type of work. Each block of time should note the duties the employee performed during that particular time period. Estimates or percentages of time spent in the different duties are not acceptable as verifiable records. LWNOREGON -2- INSURED'S COPY REMUNERATION PAYROLL "Payroll" means the TOTAL remuneration paid or payable by the employer for the services of the employees covered by the policy. Payroll INCLUDES commissions, anticipated bonuses, straight hourly wage for all hours worked, holiday pay, sick pay, piecework pay, tool allowances, value of living quarters provided by the employer, value of meals provided, value of store certificates or mechandise provided, and credits or any other substitute for money received by employees. Payroll does NOT INCLUDE profit-sharing amounts, unanticipated bonuses, vacation pay, tips or other gratuities received by employees from others, payments by the employer to group insurance or group pension plans, value of special rewards for individual invention or discovery, the value of a company-provided vehicle which is used in the employer's business, or dismissal or severance payments except for the pay earned for the time worked. It also excludes payments from a program to reward workers for safe working practices. SUBCONTRACTORS When you subcontract a portion (or all) of your work to others and retain the right to exercise any direction and control (regardless of whether that right is exercised), you will be expected to pay the premiums for that subcontracted payroll UNLESS the subcontractor has its own workers compensation insurance coverage. In order to avoid the payment of premium for your subcontractors, you should obtain a CERTIFICATE OF INSURANCE from each subcontractor. At the time of audit, your insurance carrier will ask for any certificates of insurance and will exclude the subcontractor's payroll when the certificate is available. EXPERIENCE RATING When any employer's initial policy develops an annual premium in excess of $5,000, the employer will qualify for experience rating at the beginning of the THIRD year and annually thereafter. When the employer develops premium in excess of $2,500 (but less than $5,000), they will qualify for an experience rating modification at the beginning of the FOURTH year. However, major changes in ownership may affect the continuation of individual employer data which may be used for experience rating purposes. LWNOREGON -3- INSURED'S COPY EXPERIENCE RATING (CONTINUED) Essentially, the Experience Rating Program will use your company's payroll, by individual classification, to determine the AVERAGE amount of losses expected to emerge from that payroll. It will then compare those EXPECTED LOSSES to the ACTUAL LOSSES which were paid and/or reserved for any injuries occuring during the period covered by the data used in the annual experience rating process. When your company has BETTER than average experience, the experience modification will result in a CREDIT (reduction in your final premium), but if your experience is WORSE than average, a DEBIT (Surcharge) will apply. MERIT RATING When an employer is too small to qualify for experience rating, a MERIT RATING program will apply. In general, this program will: a) reduce your final premium if there were no payments for "lost-time" injuries during the most recent year for which data has been compiled; b) will not affect your premium when there was only ONE lost-time injury; and c) will surcharge your premium when there are two or more lost-time injuries. Oregon law provides that, with the approval of regulatory authorities, insurance carriers may use their own customized merit rating plan. Maximum credits or surcharges are 10 percent. Check with your insurance carrier or agent for specific information about merit rating plans in effect in Oregon. FEDERAL COVERAGES While most employers will be subject to only the Oregon Workers Compensation Act, others MAY be subject to the Admiralty Act (for Masters or Members of a Vessel), to the Federal Employers Liability Act (Railroads engaged in Interstate Commerce), or the Longshore and Harborworkers Compensation Act (for stevedoring operations, operations, building or repairing of vessels, new construction work in connection with marinas, etc.). However, the determination of exposures under any of the Federal Acts is a legal question which should be discussed with your insurance carrier or agent. LWNOREGON -4- INSURED'S COPY FINAL PREMIUM When you obtain a policy from your insurance carrier, the premium will be ESTIMATED from the description of work and payroll information supplied by you. Your insurance carrier may either make interim audits or audit your account when your policy has expired. At that time, your final premium will be based upon the ACTUAL payrolls. OREGON CLASSIFICATION AND RATING COMMITTEE A Committee, composed of members well-versed in workers compensation insurance matters, meets periodically to hear the grievances of employers who feel they have been treated improperly in the assignment of classifications, payroll assignments, or experience ratings. (Since the 'rate' is an actuarial product which has been reviewed by the Insurance Department prior to approval for use, the appeal may NOT be based upon the rate for an individual classification). Should you feel you have been aggrieved, you may direct your specific allegations to the NCCI Northwestern Service Office, One S. W. Columbia Blvd. (Suite 850), Portland, OR 97258 or contact your carrier for further information. CONCLUSION The above information has been designed to provide you with a broad overview of the Oregon Workers Compensation Insurance system. Should you have further questions, please contact your carrier or the NCCI Northwestern Service Office at the address indicated above. LWNOREGON -5- INSURED'S COPY PAGE 001 ENDORSEMENT # 00001 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-48 Issued to: OUTSOURCE INTERNATIONAL, INC BY: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA NAMED INSUREDS FEIN -------------- ---- 00001 OUTSOURCE INTERNATIONAL, INC 592754571 00002 SYNADINE I 592754571 (DBA) PAYROLL PARTNERS 00003 LABOR WORLD OF AMERICA, INC. 592754571 (DBA) SYNADYNE III 00004 OUTSOURCE FRANCHISING, INC. 592754571 00005 SYNADINE II 650021598 (DBA)PAYROLL PARTNERS 00006 SYNADINE IV 650021598 00007 CAPITAL STAFFING FUND, INC. 592754571 00008 SMSB ASSOCIATES, INC. 592754571 ------------------------------------ AUTHORIZED REPRESENTATIVE Issue Date: 04/01/97 Iw0003 INSURED'S COPY PAGE 001 ENDORSEMENT # 00002 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-48 Issued to: OUTSOURCE INTERNATIONAL, INC By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA ADDITIONAL LOCATIONS -------------------- 00001 8000 N FEDERAL HIGHWAY BOCA RATON FL 33487 00002 2424 E. BURNSIDE STREET PORTLAND OR 97214 00003 2424 E. BURNSIDE STREET PORTLAND OR 97214 00004 2424 E. BURNSIDE STREET PORTLAND OR 97214 00005 2424 E. BURNSIDE STREET PORTLAND OR 97214 00006 2424 E. BURNSIDE STREET PORTLAND OR 97214 00007 2424 E. BURNSIDE STREET PORTLAND OR 97214 00008 2424 E. BURNSIDE STREET PORTLAND OR 97214 ------------------------------------ AUTHORIZED REPRESENTATIVE Issue Date: 04/01/97 1W0004 INSURED'S COPY ENDORSEMENT # 00003 This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-48 Issued to: OUTSOURCE INTERNATIONAL, INC By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA NOTICE OF CANCELLATION PART SIX, PARAGRAPH D.2 OF THE WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY IS REPLACED BY THE FOLLOWING: WE MAY CANCEL THIS POLICY. WE MUST MAIL OR DELIVER TO YOU NOT LESS THAN NINETY (90) DAYS ADVANCE WRITTEN NOTICE, TEN(10) DAYS FOR NON-PAYMENT OF PREMIUM STATING WHEN THE CANCELLATION IS TO TAKE EFFECT. MAILING THAT NOTICE TO YOU AT YOUR MAILING ADDRESS SHOWN IN ITEM I OF THE INFORMATION PAGE WILL BE SUFFICIENT TO PROVE NOTICE. ------------------------------------ AUTHORIZED REPRESENTATIVE Issue Date: 04/01/97 1W0014 INSURED'S COPY ENDORSEMENT This endorsement, effective 12:01 AM 01/01/97 Forms a part of policy no.: RM WC 217-79-48 Issued to: OUTSOURCE INTERNAIONAL, INC By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA THIS POLICY PROVIDES NO COVERAGE IN THE STATE OF MAINE. ------------------------------------ AUTHORIZED REPRESENTATIVE Issue Date: 04/01/97 WCB80001 INSURED'S COPY SYNADYNE CLIENT SERVICE AGREEMENT This AGREEMENT is made between the individual or firm named as CLIENT, _________________ located at ___________________________________ and SYNADYNE, a division of Outsource International, a Florida corporation. I. TERM OF THIS AGREEMENT. The term of this Agreement shall be from the COMMENCEMENT DATE as shown on Exhibit A until terminated by either party with forty-five (45) days' written notice. After notice, the termination is to occur at the end of the next calendar month or forty-five days from the date of notification, whichever is later. Until the end of the month following cancellation, the parties will continue to meet the obligations set forth in this AGREEMENT. II. PROFESSIONAL EMPLOYMENT SERVICES. By entering into this Agreement, SYNADYNE has agreed to provide Professional Employment services. SYNADYNE and CLIENT shall be as a result of this Agreement, joint employers and share responsibilities as to employees at CLIENT's worksite who are subject to this agreement according to the terms herein. It is not the intention of this Agreement to insulate CLIENT in any manner from those responsibilities which the law imposes upon it as a business or workplace. Nor is it the purpose of this Agreement for SYNADYNE to provide a pass-through payroll service. The services provided by SYNADYNE, and the fees paid by CLIENT, are not provided or paid for, as an agent of CLIENT, but are instead supplied pursuant to SYNADYNE's management of the workforce at CLIENT's workplace. M. DUTIES & OBLIGATIONS OF SYNADYNE. A. SYNADYNE agrees to provide the following services to CLIENT and the employee under the shared supervision of CLIENT and SYNADYNE including: 1. Timely payment of wages through SYNADYNE's payroll as reported by CLIENT, and the proper administration and payment of applicable employer related federal, state and local income tax withholding including Social Security and federal and state unemployment taxes. In accordance with Florida law, SYNADYNE assumes responsibility to pay said wages to employees under this Agreement without regard to payments from CLIENT, but reserves it's rights hereunder to collect said wages from CLIENT. 2. Proper administration and payment of workers' compensation premium(s) and employee benefit programs except in the event that applicable law requires CLIENT or CLIENT elects to maintain said policies. 3. Completion and maintenance of all payroll and benefit records, with the exception of the records of actual hours worked which shall be maintained and verified by CLIENT. 4. Where appropriate, hiring, and appointing of an on-site Administrative Coordinator to implement terms and conditions of this Agreement. B. SYNADYNE agrees that it will develop and maintain a set of personnel policies and procedures in a manner designed to improve human resources management in CLIENT's business. CLIENT will assist SYNADYNE in implementing these policies and procedures. 1 Form: 040797 C. Direction and Control. In order to effectively provide the Human Resources and Employee Management services outlined in this service agreement, SYNADYNE reserves and retains the authority to approve and disapprove all actions to hire, fire, discipline, determine compensation and pay employees. CLIENT reserves the right to reasonably refuse the assigment of any employee provided hereunder or to request reassignment of any employee provided hereunder. SYNADYNE also retains a right to control aspects of the worksite to which employees are assigned relating to management of safety and risk, including but not limited to safety inspections of CLIENT'S premises, promulgation and administration of employment and safety policies and management of claims and related procedures. D. SYNADYNE agrees to release, defend, indemnify and hold CLIENT harmless from any and all wrongful or negligent acts of SYNADYNE or any failure of SYNADYNE to act in performance of its duties during, the initial or extended term of the Agreement. E. SYNADYNE will provide notice of this agreement to all employees subject to it in accordance with all applicable Federal and State laws. IV. RIGHTS & DUTIES OF CLIENT. A. CLIENT will be responsible for the day-to-day supervision and control of employees assigned to CLIENT under this agreement. CLIENT will verify skills and references to determine employment eligibility of assigned employees. B. In the performance of supervisory functions of assigned employees, CLIENT agrees to follow SYNADYNE's policies and procedures. Such policies and procedures shall be made available to CLIENT prior to the assignment of employees under this agreement. SYNADYNE reserves the right to change, and/or periodically update the policies and procedures. C. CLIENT has the right to request removal or reassignment of assigned employees for good cause and with reasonable notice, or to reasonably refuse assignment of any employee. D. Work Records and Payment of Wages. CLIENT agrees to maintain records of actual time worked and verify the accuracy of wages and salaries reported to and paid by SYNADYNE. CLIENT will pay for any unpaid benefits due to assigned employees upon termination of employment, including, (but not limited to) unused vacation leave. CLIENT also agrees to pay all unpaid benefits due assigned employees if this Agreement is terminated. Unpaid benefits includes (but is not limited to) benefit plan premiums for all enrolled assigned employees until the end of the month during which this Agreement is terminated. CLIENT will be responsible for the accuracy of all work time records for all employees and verify that they are approved, verified and signed by the employee and appropriate supervisor each pay period. E. Workplace Safety and Workers' Compensation Compliance. 1. CLIENT agrees that it is primarily responsible for complying with all health, safety, and environmental rules, regulations, and statutes and that it will comply at its expense with all safety, health and work environment laws, regulations, ordinances, directives, notices, warnings, and rules imposed by controlling federal, state and local governments, including, but not limited to OSHA and it will immediately report, before the end of the current work day or shift all accidents and injuries to SYNADYNE. CLIENT agrees to provide SYNADYNE with a complete list of hazardous materials that employees may come into contact with, the proper method of handling, the dangers of each in conformity with the law and Material Safety Data Sheets for each such material. CLIENT also agrees to comply at its expense with any specific directives from SYNADYNE, its workers' compensation carrier or any government agency having jurisdiction over the work place, health and safety. CLIENT shall provide all employees protective equipment as required by federal, state or local law, regulation, ordinance, directive or rule or as deemed necessary by SYNADYNE or its workers' compensation carrier. SYNADYNE, its workers' compensation carrier and its liability insurance carriers shall have the right to inspect CLIENT's premises to ensure that employees assigned to CLIENT are not exposed to an unsafe work place. To the extent possible, such inspection shall be scheduled at a mutually convenient time. In no event shall this right, the exercise of this right or the nonexercise of this right affect any of the CLIENT's obligations to SYNADYNE and the shared employees specified in this Agreement. 2 Form: 040797 2. In the event that applicable law requires CLIENT or if CLIENT elects to maintain a policy of workers' compensation insurance, or a lawful alternative to same, CLIENT shall cause SYNADYNE to be named as altenate employer, or an additional insured on said policy or alternative coverage. 3. Light Duty Assignments. CLIENT agrees that it will provide light duty work to any person who may be entitled to same under law. If CLIENT fails or is unable to provide light duty SYNADYNE shall have the right to re-assign the employee in light duty at a different location. CLIENT shall immediately reimburse SYNADYNE for the cost of providing, any light duty work assignment, or the costs resulting from the inability to provide such light duty work. F. Insurance. 1. Vehicle, Liability, Property, Malpractice and E&O Insurance Protection. If any assigned employee is required to drive a vehicle of any kind for CLIENT, CLIENT will furnish and keep in full force and effect during the term of this Agreement liability insurance to include coverage for public liability, both bodily injury and property damage, with a minimum combined single limit of One Million Dollars ($1,000,000) and uninsured motorist insurance with a minimum combined single limit of Sixty Thousand Dollars ($60,000), or the minimum limit required by applicable state law. If an assigned employee performs any duties in a professional capacity, CLIENT agrees to exercise such direction and control over said employee sufficient to comply with all applicable laws, and CLIENT shall furnish malpractice insurance which shall cover any acts, errors or omissions, including, but not limited to, negligence. The employee shall be deemed the employee of the CLIENT for the purposes of this insurance. CLIENT agrees to cause its insurance carrier(s) to name SYNADYNE as an additional named insured on CLIENT's policy and shall provide evidence of such coverage, and shall issue a Certificate(s) of Insurance evidencing same to SYNADYNE allowing not less than thirty (30) days' notice of cancellation or material change. CLIENT agrees to file against such policy exclusively with respect to any claim for malpractice or errors and omissions or any other claim covered thereunder for any employee engaged in the performance of licensed and/or professional duties. CLIENT agrees to defend SYNADYNE, or to cause its insurance carrier to defend SYNADYNE, against any and all liabilities of any kind, including costs and attorneys' fees, arising out of any such claim. 2. General Liability Insurance Protection. CLIENT agrees to keep in full force and effect at all times during the term of this Agreement, a comprehensive general liability insurance policy in the minimum limit of One Million Dollars ($1,000.000) insuring CLIENT against bodily injury and property damage liability caused by CLIENT's premises-operations, completed operations and/or products. Said policy shall also include blanket contractual liability and personal injury liability. CLIENT shall provide SYNADYNE with a certificate of insurance evidencing such coverage, said certificate to provide thirty (30) days' notice in the event of cancellation of coverage. CLIENT agrees that with respect to any claim or event alleging or resulting in bodily injury or property damage that involves a contract employee, CLIENT agrees to file for recovery under CLIENT'S appropriate liability insurance policy. 3. CLIENT is required for its own protection to secure all necessary forms of liability insurance that CLIENT would feel essential to have if SYNADYNE assigned employees were the employees of CLIENT. G. CLIENT agrees to release, defend, unconditionally indemnify and hold SYNADYNE harmless from any and all wrongful or negligent acts committed by CLIENT or assigned employees including violations of any federal, state or local statutes, laws or regulations, as well as all liability claims involving CLIENT or assigned employees. If SYNADYNE is sued or made the subject of an investigation or administrative action, by any governmental agency; CLIENT agrees to pay all costs, including attorneys' fees incurred by SYNADYNE. Any and all damages awarded to a SYNADYNE assigned employee or his or her representative as a result of such claims will be paid by CLIENT and not SYNADYNE, or if required to be paid by SYNADYNE, CLIENT will reimburse SYNADYNE for and such award and all costs and attomeys' fees expended by SYNADYNE and/or paid to the prevailing employee. H. Special Benefits Administration Agreement. Form: 040797 3 1. If this agreement is terminated for any reason, CLIENT shall take all necessary action to replace health care coverage for employees covered by this Agreement so as to avoid the implication of a qualifying event as defined by I.R.C. /section/4980B. If CLIENT fails to provide such health care coverage, SYNADYNE shall be obligated to extend continuation of its health care coverage in accordance with I.R.C. /section/4980B, and CLIENT shall then remit to SYNADYNE the cost per employee to provide such coverage. 2. COBRA Notifications. CLIENT agrees to comply with the provisions of I.R.C. /section/4980B and to notify SYNADYNE of any event that would constitute a qualifying event under said statute as soon as it becomes aware of said event. If CLIENT fails to notify SYNADYNE of a qualifying event under IRS and /section/4980B CLIEINT shall be liable for any and all costs or penalties incurred by SYNADYNE as the result. I. Automatic Termination Conditions. In the event that any one or more of the following conditions occurs, this Agreement will be deemed to have terminated at least twenty four (24) hours immediately before the first of said event(s): (a) any condition of CLIENT which could fit the definition of financial distress under the Worker Adjustment and Retraining Notification Act; (b) the filing by CLIENT of any petition for reorganization or bankruptcy; (c) the closing of any facility or operation where 25% or more of CLIENTS employees are assigned.; (d) for non-payment of invoice. J. CLIENT's Current Compliance. CLIENT warrants that, all wages and benefits for all past and present employee(s) are current and that there is no liability for same to which SYNADYNE could succeed. CLIENT expressly agrees to indemnify, hold harmless and defend SYNADYNE from any and all liabilities, known or unknown, including without limitation costs and attorneys' fees, which could arise out of any allegation, assertion or claim that SYNADYNE is a successor employer of CLIENT. K. Compliance with Federal, State, and Local Laws. 1. CLIENT acknowledges, understands and agrees that, notwithstanding any other provisions of this Agreement, the fees charged by SYNADYNE and remitted by CLIENT are not intended to compensate SYNADYNE for the risk associated with the liabilities which may arise out of the improper management of employees or for the violation of numerous local, state, and federal employment statutes. CLIENT is responsible for complying with all federal, state and local laws, regulations and ordinances including, but not limited to, those relating to employment labor and wage and hour issues, safety and health, environmental issues, hazardous waste, access to CLIENTS premises, and accommodation of protected individuals under the law, just as if, and to the same extent as if this Agreement did not exist. 2. Premises & Accommodation Liability (ADA). The parties agree that any exposure, risk or liability for said access or accommodation or failure thereof, whether imposed by the Americans with Disabilities Act or some other federal, state or local statute, law or regulation, shall be the sole responsibility of CLIENT. 3. Family Medical Leave Act (FMLA) Compliance. It shall be CLIENT's sole responsibility to determine the size of its workforce, the number of hours of work required to meet the market demand for CLIENTS service and/or product, employee scheduling, and the suitability of individuals for any specific job duties. Accordingly, for purposes of determining whether and to what extent any individual worker can be allowed to take time off away from work for any purpose, and to what extent if any such time off would require the assignment of a replacement worker, CLIENT shall have the primary responsibility for making such determinations, and SYNADYNE shall have the secondary responsibility for implementing such aspects of said determinations as may be appropriate under this Agreement. CLIENT shall be solely responsible for all costs to comply with the FMLA, including without limitation the cost of securing a replacement job position for any worker covered by this agreement, and the cost of any benefit plan coverage associated with FMLA compliance. CLIENT shall pay all costs associated with any person placed in a job vacancy created in compliance with FMLA. L. CLIENT agrees to assist SYNADYNE in the notification of affected workers of the joint employer arrangement described herein, and in obtaining worker acknowledgment of same. 4 Form: 040797 V. SERVICE FEES. A. Employment Enrollment Fee. On or before the commencement date, CLIENT will pay to SYNADYNE an INITIAL ENROLLMENT FEE for each position shown on Exhibit B. An ENROLLMENT FEE will also be due when new employees are added to CLIENT's payroll (including replacement employees for those listed on Exhibit B and any employees hired for newly established positions). B. The Administrative Fee. The Administrative Fee charged to the CLIENT and payable at the end of each pay period will be equal to the rate specified on Exhibit B. Any increase or decrease in the Administrative Fee for statutory increases in employment taxes, shall be effective on the date of such increase or decrease. Workers' compensation and employee health benefit costs will also be adjusted as of the effective dates. A thirty (30) day notification shall be required of SYNADYNE before changes are to be made in SYNADYNE's Administrative Fee (see Exhibit B) charged to the CLIENT. C. Other Service Fee Components. CLIENT will pay, at the end of each regular or special pay period all additional costs or expenses incurred at the request of CLIENT, including replacement personnel or temporary personnel obtained from SYNADYNE, any assigned field supervisor, safety engineering, fidelity bonding, professional liability insurance, overnight mail charges, continuing education, etc. D. All payments to SYNADYNE by CLIENT will be made upon presentation. A late payment charge of two (2) percent will be added to all accounts not paid when due. Bankdrafts returned unpaid from CLIENT's bank will be subject to the late payment charge plus any additional costs incurred by SYNADYNE. An unpaid balance will also be subject to a periodic charge of one and one-half (1 and 1/2) percent per calendar month until paid. SYNADYNE reserves the right to suspend the services to CLIENT until full payment has been made of any amount past due and SYNADYNE may impose a 20% late payment fee, or the highest fee allowed by law. VI. GENERAL PROVISIONS A. Entire Agreement. This Agreement constitutes the entire agreement between the parties and supersedes any and all agreements, whether oral or written, between the parties with respect to its subject matter. If an action is brought by either party hereto for breach or default of any provision of this Agreement, the prevailing party in such action shall be awarded reasonable attorneys' fees and costs in addition to any other relief to which the party may be entitled. B. Modification. This Agreement may not be altered or amended except by written agreement duly executed by all parties hereto. C. Successors. This Agreement shall be binding upon and shall inure to the benefit of the parties hereto and their respective heirs, executors, administrators, legal representatives, successors and assigns. D. Counterparts. This Agreement may be executed in several counterparts, each of which shall be deemed an original, and such counterparts shall together constitute but one and the same agreement, binding upon all the parties hereto, notwithstanding that all the parties are not signatories to the original of the same counterpart. E. Headings. The headings and labels of the paragraphs of this Agreement are inserted solely for the convenience of reference, and in no way define, limit, extend or aid in the construction of the scope, extent or intent of this Agreement or of any term or provision hereof. F. Severability. Should any term, warranty, covenant, condition or provision of this Agreement be held to be invalid or unenforceable, the balance of this Agreement shall remain in force and shall stand as if the unenforceable part did not exist. G. Choice of Law. This Agreement shall be governed by and construed in accordance with the laws of the State of Florida and jurisdiction shall rest with applicable Florida courts. Both parties acknowledge the personal jurisdiction of the courts in and for Broward County, Florida. Both parties acknowledge and agree to service of process from the courts in and for Broward County, Florida. All suits and special proceedings arising out of this Agreement shall be brought in the courts 5 Form: 040797 in and for Broward County, Florida, unless the parties agree to mediate or arbitrate their dispute as provided in /section/ H below. The parties agree and hereby irrevocably submit any suit, action or proceeding arising out of or related to this Agreement or any of the transactions contemplated by this Agreement to the jurisdiction and venue of the United States District Court for the Southern District of Florida or the jurisdiction and venue of any court of the State of Florida located in Broward County and waive any and all objections to jurisdiction and venue that they may have under the laws of Florida or the United States. H. Arbitration and Mediation. All disputes and alleged breaches arising out of or relating to this Agreement may be resolved by way of mediation and arbitration as set forth herein. If a dispute under this Agreement arises, either party may serve written notice on the other that it desires to have the dispute submitted to mediation in accordance with the procedures of the Federal Mediation & Conciliation Service, pursuant to Chapter 44, Florida Statutes or as otherwise agreed by the parties to the dispute. Once elected, a mediation conference shall be scheduled with 30 days in the City of Deerfield Beach, Florida. If the dispute is not resolved through mediation, the parties shall submit their dispute to binding arbitration within 30 days after impasse is declared by a mediator. The Arbitration shall be conducted by a committee of arbitrators (one appointed by SYNADYNE, one appointed by CLIENT and one appointed by the two arbitrators so appointed), in the City of Deerfield Beach, Florida, and pursuant to the terms of the Florida Arbitration Code Chapter 682, et. seq, Florida Statutes. The arbitrators shall abide by the rules of the American Arbitration Association and their decision shall be final and binding on both parties. Judgment may be obtained on the arbitration award in any court of competent jurisdiction. Completion of mediation until resolution or impasse is a condition precedent to arbitration. I. Waiver. The failure of any party to enforce at any time the provisions of this Agreement shall not be construed as a waiver of any provision or of the right of such party thereafter to enforce each and every provision of this Agreement. J. Assignment. CLIENT shall not transfer or assign this Ageement or any part thereof without the prior written consent of SYNADYNE. This Agreement may be assigned by SYNADYNE at its sole discretion. K. Default & Termination. In addition to the means of termination specified in /section/V,I above, this Agreement may also be terminated by CLIENT's default, at SYNADYNE's sole discretion. Acts of default by CLIENT shall include: 1. Failure of CLIENT to pay any monies due under this Agreement. 2. Failure of CLIENT to comply within the time specified by SYNADYNE with any directive of SYNADYNE when such directive is promulgated or made necessary by (i) a federal, state or local governmental body, department or agency, (ii) an insurance carrier providing coverage to SYNADYNE and/or the employees and/or (iii) specific circumstances which currently or potentially affect SYNADYNE, CLIENT or employees covered by this Agreement. 3. Direct payment of taxable wages by CLIENT to SYNADYNE assigned employees for services contemplated by this Agreement. Any breach or default of any material term or condition of this Agreement shall, unless the innocent party elects otherwise in writing, cause immediate termination of this Agreement. Notwithstanding same, the innocent party is required to provide immediate written notice of any material breach or default. The effective date of termination shall be deemed to be the date the violation occurs, not when discovered or when notice is received by either party. L. Notices. Any notice, request, demand or other communication required or permitted hereunder shall be deemed to be properly given when deposited with the United States Postal Service, postage prepaid, or when deposited with a public telegraph company for transmittal, charges prepaid and addressed: 1. In the case of SYNADYNE, to SYNADYNE, 1144 East Newport Center Drive, Deerfield Beach, Florida 33442 or to such other person or address as SYNADYNE may furnish to CLIENT. 2. In the case of CLIENT, to ___________________________ or to such other person or address that CLIENT may furnish from time to time to SYNADYNE. 6 Form: 040797 M. Time Is Of The Essence. Time is of the essence in the performance of this Agreement. N. No Third Party Beneficiaries. The parties acknowledge and agree that this Agreement creates no rights for or in favor of any person or third party not a party to this Agreement, and that no such person may place any reliance hereon. CLIENT Signature ________________________________ Date ________________ Print Name and Title ____________________________________________ SYNADYNE Signature ________________________________ Date ________________ Print Name and Title ____________________________________________ 7 Form: 040797