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Da���i� area <br />Name of Grnup• <br />11alue of Meiaber : <br />Address - <br />12/22/2011'* x1Q: <br />BUILDERS MUTUAL INSURANCE CO." <br />BROWN BROTHERS PLUMBING & HEATING CO INC <br />PO BOX 15668 <br />DURHAM,'NC 27704 <br />Policy. Number • WCF 0044355 03 <br />po�� cy Period - I12131/201i to 12/31/2012 <br />Effective Date. 12/31/2011 <br />• 37354 <br />INTENT OF EIJDORSEMENT (- ZTDICATE ONLY 01TE ACTION PER EIMORSEMENT) . <br />( X ) CI ANGES TO WAIVER OF SIISROGATION SCHEDULE- <br />INSTRUCTIONS: <br />For changes, indicate below the name or } Indicate below the new name or address <br />address prior to endorsement. Each item } after change or the name and address of an <br />On the left must correspond with an item } addition or deletion. For deletions give <br />on the right. } disposition. <br />} <br />00002 BLANI= NAIVSR <br />Applies to all,jobs as required by <br />} wrttten contract. <br />I - 2820 N_ ' ox '6oro Ind. <br />I 'Duxbam, NC 27704 <br />I <br />I <br />I <br />I <br />Agent: 443 - TYSON INSURANCE SERVICES. <br />Reguestor: DWRITAK <br />STATE ?NGURED PIL9 AGENT LC <br />