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WC tai? 00 01A <br />AMERISURE INSURANCE COMPANY NCCI Code No. 11525 <br />b mnm WORKERS' COMPENSATION AND EMPLOYERS` L.1A1~ UTY <br />ruing Office <br />CHAMO M RRANCH <br />PWCY Nta[. BLq Rend of Agent Producer <br />WC - 2013881.06 WC -2 11USI -04 081527$ WACHOVIA INS SERVSAAtEWH <br />Itern 1. Nam of Insured and Addrem - Other ces Not Shown partr�rship <br />I {5 ns+on to Pie) X p� or <br />RESOLME SUILDING COMPANY, TIME <br />PO BOX 3656 FED NO. 561334110$1 <br />CHARM HILL, NO 27515 INTRA NO- NC 2104304 <br />INTER NO. <br />CUST W NO. 10585191 <br />GROUP; <br />POLICY "t EXTENSION OF INFORMATION PAGE - ITEM 3D "" SCHEDULE <br />PAGE 2 k" ENDORSEMENT SCHEDULE PAGE 1 <br />STATE NUMBER DESCRIPTION � - � � �.� EDITION <br />DA'L'E <br />THE FOLLOWING CHANGES, IF ANY, HAVE BEEN MADE TO THIS SCHEDULE <br />ENDT B MANUSCRIPT ENDORSEMENT01i01l1995 <br />• Issue Date 10/2412007 <br />INSURED COPY <br />