250 West Main Street, Suite 900 Lexington, KY 40507-1724 859-425-7800 www.kemi.com

00913 Kentucky State University Attn Candice Raglin Director of HR 400 E Main St ASB-429A Frankfort, KY 40601

Kentucky State University Attn Candice Raglin Director of HR 400 E Main St ASB-429A Frankfort, KY 40601

Kentucky Employers Mutual Insurance 250 W Main Street, Suite 900 Lexington, KY 40507 www.kemi.com 859-425-7800 / 800-640-5364

Quote Date: June 6, 2022

Legal Entity: Other FEIN: 611099712

Prospective Insured:

Name: Kentucky State University

Address: Attn Candice Raglin Director of HR 400 E Main St ASB-429A

City: Frankfort, KY 40601

Agency: AssuredPartners NL Insurance LLC

Agent Number: 633

Address: 2305 River Rd

City: Louisville, KY 40206

Phone: (502)894-2100

Renewal Quote for Workers Compensation Coverage 398982-07/01/2022-07/01/2023

Proposed Effective Date: 07/01/2022 Proposed Expiration Date: 07/01/2023

Employer’s Liability Limits: (3.B) Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease

PLAY 398962 RECIPI: In B068 32000 CHES: m AGNT 103985 Page 1 of 40

Proposed Expiration Date: 07/01/2023

Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease

$1,000,000 each accident

$1,000,000 policy limit

$1,000,000 each employee

June 6, 2022

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