BINDER CONFIRMATION WORKERS COMPENSATION t f
December 16;.2014
RE DR.MARTIN LUTHER KING JR NEIGHBORHOOD FAMILY CENTS
Quote 4: WC-343570
Binder:##: WC-610317
We are pleased to confirm coverage for the above account
Enclosed.you will find the binder c.onfzmation and invoice.for payment. Kindly review since the
coverage, terms and conditions may different from those requested in your original. submission..
Please read carefully and contact our office.should you have any questions and/or concerns.
Thank you for allowing us the opportunity to service you and your client.
Best Regards,
Ascendant Underwriters
RO.Box 260490 Miami,Florida 33126•Phone.(305) 820-4360•Fax(305) 820-4348.
Ascendant Underwriters, LLC Binder Number: WC-610317-0
P.O. Box:260490 Date Bound : 12/16/2014
Miami,FL 33126 Policy Term :. 01/07/2015 To: 01107!2016
Phone: (305):820=4360
Fax: (305)820-4348
PAY ONLINE
at www.ascendantgroup.com
BINDER CONFIRMATION
WORKERS COMPENSATION
Insured: Brokering Agent:
DR.IVIARTIN LUTHER.KING.JR.NEIGHBORHOOD FAMILY CENTS VIKING.UNDERWRITERS
900.N DR:.MLK JR AVE 16506 BOTANCIA PL
CLEARWATER, FL 33755 LUTZ, FL 33558.
Code : 5256
Phone; (704)287-3876
Fax
Quote Number: WC-34:3570-0-0
Quote Date: 1111.812014
[.X] New [] Renewal.
Underwriter: mlopez
BUSINESS DESCRIPTION: CORPORATION
CCVERAGE Ct7DI .L`IMIT Amount t ACIQFt PR£MILIM
Manual Premium (See Classifications:) 4,023.00
Employers.Liabillty Limits 10oI5.0o/1.00 0:00
Coinsurance 0.00
SUBJECT PREMIUM 41023.00
SafetyCredit 97:65 0,00
... ...... ..........
Drug Free Credit 9841 0:00
TOTAL SUBJECT PREMIUM 4„023:00
Experience Mod 9898 1.:00' 0:00
TOTAL MODIFIED.PREMIUM 4,623.00
CCPAP 9046 0:00
TOTAL.STANDARD PREMIUM 4,:023.00
.. ..... .... ....... .... .. ..... .. . .........
Premium Discount 0063 0:00
Expense Constant 0900 200:00
Terrorism Risk Insurance 9740 50.00
ESTIMATED ANNUAL PREMIUM $4,273.00
Payment of $854.60 must be received no later than 12/21/2014..
You can now review your binder online and make Payments at www.ascerrdantgfoup.com
Ascendant Underwriters, LLC Binder Number: WC-610317-0
P.O. Box 260490 Date Bound : 12/16/2014
Miami, FL 33126 Policy Term : 01/07/2015 To: 01/07/2016
Premium Basis: Rate per
Class Estimated Annual $100 of Manual
Code Classifications Period Remuneration Remuneration Premium
8864 SOCIAL SERVICES ORGANIZATION-ALL 01/07/2015 To 01/07/2016 $251,449 1.60 4,023.00
EMPLOYEES&SALESPERSONS,DRIVERS
ADDITIONAL ENTITIES:
ASCENDANT COMMERCIAL INSURANCE, INC. Invoice
P.O.Box 260490 Number: 61005
Miami,Florida 33126 Date: 12/16/2014
Local: (305) 820-4360 Binder WC-610317
Toll Free: (877) 834-4990 Due Date: 12/21/2014
Fax: (305) 820-4348
Insured: DR.MARTIN LUTHER KING JR NEIGHBORHOOD FAMILY CENTS
900 N DR. MLK JR AVE
CLEARWATER, FL 33755
WORKER'S COMP INSURANCE BINDER -WC-6'10311
Payment Option Description Amount pue
Base Premium $4,273.00
Direct Bill Policy Fee $0.00
F.H.C.F Fee $0.00
Total $4,273.00
Minimum Payment $854.60
Commissions under the Direct Bill payment option are paid on premiums collected within the prior month. An agent
commission statement will accompany the commission check, paid on the 15th of each month.
Please write your binder number on your check and make your check payable to:
Ascendant Commercial Insurance, Inc.
P.O. Box 260490
Miami, Florida 33126
For your convenience we accept credit cards as well as checks. In order to process a credit
card or payment by check online, please visit our website at www.ascendantgroun.com or
call our customer service line at (305) 820-4360.
Please detach here and return with your paytnent,
Write the binder number on the check and snake payable to Ascendant Commercial htsurnnce,Inc..
❑Check here and indicate mailing address changes on the back. Invoice Number: 61005
Date: 12/16/2014
Mail Payments to: Binder WC-610317
Remaining Balance: $4,273.00
Ascendant Commercial Insurance,Inc. Due Dake., 12/21/2014
P.O.Box 260490 Minimum Due; $854.60
Miami,Florida 33126 Amount Enclosed $
We appreciate your business!
Form: Binder Invoice—DB Only