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111 : 1 <br />is��1! {�liwrl�:�~moi <br />r��,ir7►:►`rl sie�rl+�� <br />01 R T H♦+#rteCC A R • <br />SSOCIATION OF COUNTY COMMISSIONERS <br />NCACC Risk Management Pools <br />Worker's Compensation <br />Payment Plan Available: Workers' Compensation Pool Quoted on: 5/9/2016 <br />County or Entity: LEE COUNTY <br />Annual Payment Plan: (due on or before August 1, 2016) <br />$387,814 <br />I understand that changes made to the exposures subsequent to submission of the <br />renewal application may result in changes to the Estimated Contribution: <br />Accepted by: <br />Signature <br />Printed Name <br />Print Title <br />Date Co _ 14, (� <br />This instrument has been pre -audited in the manner required by the Government Budget and Fiscal Control Act. <br />Financial Officer: <br />Signature <br />64 ti - <br />Date L1 % ji l I t-, <br />NCACC 5/9/2016 <br />