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WORKERS' COMPENSATION <br /> CERTIFICATE OF COVERAGE <br /> ISSUED BY OR ON BEHALF OF THE VOLUNTEER SAFETY <br /> WORKERS' COMPENSATION FUND <br /> NAME AND ADDRESS OF FUND PARTICIPANT <br /> CEDAR GROVE FIRE DEPARTMENT INC <br /> ATTN: JEFF BORLAND-CHIEF <br /> 720 HAWKINS RD. <br /> CEDAR GROVE, NC 27231-0000 <br /> This company is a qualified self-insured in the state of North Carolina for its <br /> Workers' Compensation liabilities pursuant to all statutory requirements under <br /> section 97-93 of the North Carolina Workers'Compensation Act. <br /> CLIENT NUMBER: 911-984-0 <br /> COVERAGE PERIOD FROM: 07/01/13 TO 07/01/14 <br /> RENEWAL PREMIUM. $ 2,405 <br /> EMPLOYERS LIABILITY LIMITS: $100,000 Each Accident <br /> $500,000 Disease-Policy Limit <br /> $100,000 Disease-Each Employee <br /> AUTHORIZED AGENT: <br /> DATE: 08/01/2013 <br /> KEY RISK MANAGEMENT SERVICES, INC. <br /> P.O. BOX 49129 <br /> GREENSBORO, NC 27419 <br /> AGENCY: <br /> Code 3 Insurance, 16089 <br /> P. 0. Box 296 <br /> Pikeville, NC 27863-0000 <br /> VOLUNTEER SAFETY <br /> - "JE3uKEF:" O Ar..N,11A11-;NFtINt __. _ <br />