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First Dakota Indemnity Company 35866 1. Insured Information Page Policy No.: WCO20-0046074-2020A Renewal of No.: WCO20-0046074-2019A Fed. I.D. No.: 411676172 Risk I.D. No.: 1548590 Association No: Unemployment No.: 13393750000 The insured: Saturn of St Paul Inc Mailing address: 3400 Hwy 61 N White Bear Lake, MN 55110 Other workplaces not shown above: (See Attached Schedule) (WC 99 06 06) (See Attached Schedule) (WC 99 06 06) Insured is a Corporation 2. Policy Period The policy period is from 10/1/2020 to 10/1/2021 12:01 AM at the insured's mailing address. 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MN, B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All other states except those designated in item 3A or monopolistic states. D. This policy includes these endorsements and schedules: (See Attached Schedule) (WC 99 06 04) 4. Premium 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. Total Estimated Annual Rate per $100 of Estimated Code No. Classifications Remuneration Remuneration Annual Premium (See Attached Schedule) (WC 99 06 05) Minimum Premium: $682 Expense Constant: $220 Total Estimated Annual Premium: $47,789 Date: 10/1/2020 Agent: USI Insurance Services LLC Mailing 8000 Norman Center Drive Suite 400 Address: Bloomington, MN 55437 Copyright 1982 National Council on Compensation Ins. WC 7-84 WC 00 00 01 A